Healthcare Provider Details

I. General information

NPI: 1558484410
Provider Name (Legal Business Name): MIDWEST FAMILY DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2007
Last Update Date: 08/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 MARYVILLE RD
GRANITE CITY IL
62040-5119
US

IV. Provider business mailing address

3120 MARYVILLE RD
GRANITE CITY IL
62040-5119
US

V. Phone/Fax

Practice location:
  • Phone: 618-797-9940
  • Fax:
Mailing address:
  • Phone: 618-797-9940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019-023663
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. LANEY ELAYNE SCHUMAN-BOYS
Title or Position: PRESIDENT
Credential: DMD
Phone: 618-797-9940