Healthcare Provider Details

I. General information

NPI: 1932029907
Provider Name (Legal Business Name): INNOVATION DENTAL AND IMPLANT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 INSIGHT AVE
O FALLON IL
62269-2151
US

IV. Provider business mailing address

1922 EDWARDSVILLE CLUB PLAZA CT
EDWARDSVILLE IL
62025-3717
US

V. Phone/Fax

Practice location:
  • Phone: 618-277-6550
  • Fax:
Mailing address:
  • Phone: 618-277-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DIANA LIFRITZ
Title or Position: DIRECTOR OF HUMAN RESOURCES
Credential:
Phone: 618-873-7500