Healthcare Provider Details

I. General information

NPI: 1215912696
Provider Name (Legal Business Name): SOUTHERN ILLINOIS UNIVERSITY EDWARDSVILLE SCHOOL OF DENTAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 COLLEGE AVE
ALTON IL
62002-4700
US

IV. Provider business mailing address

2800 COLLEGE AVE
ALTON IL
62002-4700
US

V. Phone/Fax

Practice location:
  • Phone: 618-474-7080
  • Fax: 618-474-7029
Mailing address:
  • Phone: 618-474-7080
  • Fax: 618-474-7029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19018978
License Number StateIL

VIII. Authorized Official

Name: DR. DEBRA M SCHWENK
Title or Position: ASSOCIATE DEAN FOR CLINICAL AFFAIRS
Credential: DMD
Phone: 618-474-7080