Healthcare Provider Details

I. General information

NPI: 1740697333
Provider Name (Legal Business Name): ORAL FACIAL SURGERY INSTITUTE OF ILLINOIS P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 WEST MAIN STREET
BELLEVILLE IL
62223
US

IV. Provider business mailing address

10200 WEST MAIN STREET
BELLEVILLE IL
62223
US

V. Phone/Fax

Practice location:
  • Phone: 618-397-2464
  • Fax: 618-398-4450
Mailing address:
  • Phone: 618-397-2464
  • Fax: 618-398-4450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT E GRAHAM
Title or Position: ADMINISTRATOR
Credential: MHA, FACMPE, FAADOM
Phone: 314-413-6043