Healthcare Provider Details

I. General information

NPI: 1700221074
Provider Name (Legal Business Name): KEITH CLARENCE WINTERNHEIMER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 NORTH COURT
GRAYVILLE IL
62844-1002
US

IV. Provider business mailing address

610 NORTH COURT
GRAYVILLE IL
62844-1002
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019024049
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: