Healthcare Provider Details

I. General information

NPI: 1053582189
Provider Name (Legal Business Name): SOUTHERN ILLINOIS UNIVERSITY CARBONDALE DENTAL SEALANT PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 DOUGLAS DR RM 18 CASA, SAH, MC 6615
CARBONDALE IL
62901-2583
US

IV. Provider business mailing address

1365 DOUGLAS DR RM 18 CASA, SAH, MC 6615
CARBONDALE IL
62901-2583
US

V. Phone/Fax

Practice location:
  • Phone: 618-453-7211
  • Fax: 618-453-7020
Mailing address:
  • Phone: 618-453-7211
  • Fax: 618-453-7020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER R KREID
Title or Position: DSGP PROGRAM COORDINATOR
Credential: RDH, PHDH, BSDH
Phone: 618-453-8823