Healthcare Provider Details

I. General information

NPI: 1548022049
Provider Name (Legal Business Name): APPLEWHITE DENTAL ILLINOIS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N WILLIAMSBURG DR
BLOOMINGTON IL
61704-3528
US

IV. Provider business mailing address

9825 KENWOOD RD STE 200
BLUE ASH OH
45242-6252
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-3123
  • Fax: 309-661-0798
Mailing address:
  • Phone: 513-808-4984
  • Fax: 513-448-0511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TY JUSTICE
Title or Position: DIRECTOR, CREDENTIALING & PROVIDER
Credential:
Phone: 513-808-4984