Healthcare Provider Details

I. General information

NPI: 1477645216
Provider Name (Legal Business Name): KEITH C WINTERNHEIMER DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 NORTH COURT
GRAYVILLE IL
62844-1002
US

IV. Provider business mailing address

4301 S POSEY COUNTY LINE ROAD
EVANSVILLE IN
47712-9301
US

V. Phone/Fax

Practice location:
  • Phone: 618-375-6341
  • Fax:
Mailing address:
  • Phone: 812-985-7772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12009321A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019024049
License Number StateIL

VIII. Authorized Official

Name: DR. KEITH CLARENCE WINTERNHEIMER
Title or Position: PRESIDENT
Credential: DDS
Phone: 812-985-7772