Healthcare Provider Details

I. General information

NPI: 1508619297
Provider Name (Legal Business Name): LAUREN ELIZABETH BERKENBILE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 MAGNOLIA DR
GLEN CARBON IL
62034-1595
US

IV. Provider business mailing address

5 MEADOWBROOKE DR
TROY IL
62294-2456
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-5437
  • Fax:
Mailing address:
  • Phone: 618-315-3399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2024021557
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number019.036882
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: