Healthcare Provider Details

I. General information

NPI: 1760467146
Provider Name (Legal Business Name): SOUTHERN ILLINOIS UNIVERSITY EDWARDSVILLE SCHOOL OF DENTAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E BROADWAY
E ST LOUIS IL
62201-2904
US

IV. Provider business mailing address

2800 COLLEGE AVE
ALTON IL
62002-4700
US

V. Phone/Fax

Practice location:
  • Phone: 618-682-8318
  • Fax: 618-474-7029
Mailing address:
  • Phone: 618-474-7090
  • Fax: 618-474-7029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19018978
License Number StateIL

VIII. Authorized Official

Name: DR. DENNIS E SAVOCA
Title or Position: ASSOCIATE DEAN FOR CLINICAL AFFAIRS
Credential: D.D.S., M.S.
Phone: 618-474-7090