Healthcare Provider Details

I. General information

NPI: 1750555470
Provider Name (Legal Business Name): GREG JONES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3704 PONTOON RD
GRANITE CITY IL
62040-4240
US

IV. Provider business mailing address

3704 PONTOON RD
GRANITE CITY IL
62040-4240
US

V. Phone/Fax

Practice location:
  • Phone: 618-931-3368
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416S0300X
TaxonomyWater Ambulance
License Number
License Number StateIL

VIII. Authorized Official

Name: GREG JONES
Title or Position: DMD PC
Credential:
Phone: 618-931-3368