| NPI | 1962162883 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | HILLARY THULL Credentialing COO Rdinator 217-540-8946 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery |
| Additional Taxonomies | 1223P0106X Dentist Oral and Maxillofacial Pathology |
| Enumeration Date | 2021-12-20 |
| Last Update Date | 2022-07-20 |