Healthcare Provider Details

I. General information

NPI: 1184978157
Provider Name (Legal Business Name): MEAGAN ELISE GRAUL DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 W SAINT LOUIS ST STE 1
LEBANON IL
62254-1515
US

IV. Provider business mailing address

229 W SAINT LOUIS ST STE 1
LEBANON IL
62254-1515
US

V. Phone/Fax

Practice location:
  • Phone: 618-537-2017
  • Fax:
Mailing address:
  • Phone: 618-537-2017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019029198
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: