Healthcare Provider Details

I. General information

NPI: 1770632119
Provider Name (Legal Business Name): SMICHAEL VANCIL DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 CEDAR COURT
CARBONDALE IL
62901-5335
US

IV. Provider business mailing address

1255 CEDAR COURT
CARBONDALE IL
62901-5335
US

V. Phone/Fax

Practice location:
  • Phone: 618-529-3931
  • Fax: 618-529-1011
Mailing address:
  • Phone: 618-529-3931
  • Fax: 618-529-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number019017293
License Number StateIL

VIII. Authorized Official

Name: S MICHAEL VANCIL
Title or Position: MEMBER
Credential: DMD
Phone: 618-529-3931