Healthcare Provider Details

I. General information

NPI: 1750390373
Provider Name (Legal Business Name): BELLWOOD FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N BELLWOOD DR
EAST ALTON IL
62024-2038
US

IV. Provider business mailing address

321 N BELLWOOD DR
EAST ALTON IL
62024-2038
US

V. Phone/Fax

Practice location:
  • Phone: 618-258-0028
  • Fax: 618-258-1060
Mailing address:
  • Phone: 618-258-0028
  • Fax: 618-258-1060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY M LAUTZ
Title or Position: DENTIST, OWNER
Credential: DMD
Phone: 618-258-0028