Healthcare Provider Details

I. General information

NPI: 1700206406
Provider Name (Legal Business Name): SONES FAMILY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GLEN ED PROFESSIONAL PARK
GLEN CARBON IL
62034-3333
US

IV. Provider business mailing address

21 GLEN ED PROFESSIONAL PARK
GLEN CARBON IL
62034-3333
US

V. Phone/Fax

Practice location:
  • Phone: 618-656-0608
  • Fax: 618-656-0615
Mailing address:
  • Phone: 618-656-0608
  • Fax: 618-656-0615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019028342
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. JONATHAN MICHAEL SONES
Title or Position: OWNER
Credential: D.M.D.
Phone: 618-656-0608