Healthcare Provider Details

I. General information

NPI: 1285972828
Provider Name (Legal Business Name): CARMI DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2013
Last Update Date: 01/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W MAIN ST
CARMI IL
62821-1387
US

IV. Provider business mailing address

1400 W MAIN ST
CARMI IL
62821-1387
US

V. Phone/Fax

Practice location:
  • Phone: 618-382-4181
  • Fax: 618-382-3590
Mailing address:
  • Phone: 618-382-4181
  • Fax: 618-382-3590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: APRIL CHILDERS
Title or Position: DENTAL OPERATIONS SUPERVISOR
Credential:
Phone: 618-253-8450