Healthcare Provider Details

I. General information

NPI: 1437539350
Provider Name (Legal Business Name): MIDWEST FAMILY DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 08/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 APEX DR STE 2
HIGHLAND IL
62249-1296
US

IV. Provider business mailing address

10 APEX DR STE 2
HIGHLAND IL
62249-1296
US

V. Phone/Fax

Practice location:
  • Phone: 618-654-2080
  • Fax: 618-654-2090
Mailing address:
  • Phone: 618-654-2080
  • Fax: 618-654-2090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019023663
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: LANEY ELAYNE SCHUMAN-BOYS
Title or Position: PRESIDENT
Credential: DMD
Phone: 618-654-2080