Healthcare Provider Details

I. General information

NPI: 1639291875
Provider Name (Legal Business Name): JOLIET ORAL SURGEONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 W JEFFERSON ST
JOLIET IL
60435-6811
US

IV. Provider business mailing address

1011 W JEFFERSON ST
JOLIET IL
60435-6811
US

V. Phone/Fax

Practice location:
  • Phone: 815-727-7748
  • Fax: 815-727-1787
Mailing address:
  • Phone: 815-727-7748
  • Fax: 815-727-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number19015979
License Number StateIL

VIII. Authorized Official

Name: MR. GLENN SCHEIVE
Title or Position: ORAL SURGEON D.D.S.
Credential:
Phone: 815-727-7748