| NPI | 1962831719 |
|---|---|
| Doing Business As | MY VICKSBURG DENTIST |
| Entity Type | Organization |
| Authorized Contact | KIM WILSON Cred. Supervisor 217-540-5170 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2013-11-02 |
| Last Update Date | 2013-11-02 |