Healthcare Provider Details

I. General information

NPI: 1063552453
Provider Name (Legal Business Name): AFFORDABLE DENTAL OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
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:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: RONALD D GERSTEN
Title or Position: OWNER
Credential:
Phone: 618-286-4400