| NPI | 1972377174 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GRANT STEVEN SEVERS President 217-919-5008 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics |
| Enumeration Date | 2023-11-08 |
| Last Update Date | 2023-11-08 |