Healthcare Provider Details

I. General information

NPI: 1114191061
Provider Name (Legal Business Name): JESSE J STINAUER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 N MAIN ST
LEWISTOWN IL
61542-9624
US

IV. Provider business mailing address

2000 N MAIN ST
LEWISTOWN IL
61542-9624
US

V. Phone/Fax

Practice location:
  • Phone: 309-547-2200
  • Fax: 309-547-2022
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.027086
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: