Healthcare Provider Details

I. General information

NPI: 1659957850
Provider Name (Legal Business Name): SIU DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 UNIVERSITY PARK DR
EDWARDSVILLE IL
62025-3645
US

IV. Provider business mailing address

2800 COLLEGE AVE BLDG 273
ALTON IL
62002-4700
US

V. Phone/Fax

Practice location:
  • Phone: 618-650-5781
  • Fax: 618-650-5790
Mailing address:
  • Phone: 618-474-7100
  • Fax: 618-474-7150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH NOEL PHELPS
Title or Position: BUSINESS MANAGER
Credential:
Phone: 618-474-7104