| NPI | 1962883926 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRANDON ALEXANDER TAYLOR Credentialing & Payer Relations Man 847-453-7396 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center Dental |
| Additional Taxonomies | 1223G0001X Dentist General Practice |
| Enumeration Date | 2015-06-16 |
| Last Update Date | 2021-06-25 |