| NPI | 1992861637 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CASSANDRA PETERSEN Credentialing Team Lead 217-540-8972 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA 7624) |
| Enumeration Date | 2006-12-28 |
| Last Update Date | 2018-08-29 |