Healthcare Provider Details

I. General information

NPI: 1487968814
Provider Name (Legal Business Name): AFFORDABLE DENTISTRY OF IL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 S MAIN ST
DUPO IL
62239-1347
US

IV. Provider business mailing address

195 S MAIN ST
DUPO IL
62239-1347
US

V. Phone/Fax

Practice location:
  • Phone: 618-286-4400
  • Fax:
Mailing address:
  • Phone: 618-286-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number319017393
License Number StateIL

VIII. Authorized Official

Name: BRIAN MATTHEW STEGMANN
Title or Position: DENTIST/OWNER
Credential:
Phone: 618-286-4400