Healthcare Provider Details

I. General information

NPI: 1356897433
Provider Name (Legal Business Name): COLUMBIA DENTAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N MAIN ST ST #2
COLUMBIA IL
62236-1157
US

IV. Provider business mailing address

915 N MAIN ST ST #2
COLUMBIA IL
62236-1157
US

V. Phone/Fax

Practice location:
  • Phone: 618-281-6161
  • Fax:
Mailing address:
  • Phone: 618-281-6161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number019027680
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019027680
License Number StateIL

VIII. Authorized Official

Name: DR. RICK LEPPO
Title or Position: OWNER
Credential: D.M.D.
Phone: 618-281-6161