Healthcare Provider Details

I. General information

NPI: 1760487219
Provider Name (Legal Business Name): WILLIAM M DONDANVILLE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N MAIN ST
BRIGHTON IL
62012-1041
US

IV. Provider business mailing address

5 FRONTENAC PL
GODFREY IL
62035-1709
US

V. Phone/Fax

Practice location:
  • Phone: 618-372-8422
  • Fax: 618-372-8744
Mailing address:
  • Phone: 618-466-4476
  • Fax: 618-372-8744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: