Healthcare Provider Details

I. General information

NPI: 1518698323
Provider Name (Legal Business Name): EMILY MARIE BORN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4241 STATE HIGHWAY 14
CHRISTOPHER IL
62822-1037
US

IV. Provider business mailing address

4241 STATE HIGHWAY 14
CHRISTOPHER IL
62822-1037
US

V. Phone/Fax

Practice location:
  • Phone: 618-724-2401
  • Fax:
Mailing address:
  • Phone: 618-724-2401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020017222
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: