Healthcare Provider Details

I. General information

NPI: 1275663338
Provider Name (Legal Business Name): ORAL & MAXILLOFACIAL SURGEONS OF CENTRAL ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5009 A EXECUTIVE DR
PEORIA IL
61614-4866
US

IV. Provider business mailing address

5009 A EXECUTIVE DRIVE
PEORIA IL
61614-4866
US

V. Phone/Fax

Practice location:
  • Phone: 309-693-1200
  • Fax: 309-693-9998
Mailing address:
  • Phone: 309-693-1200
  • Fax: 309-693-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. ROBERT WILLIAM YOUNG
Title or Position: ORAL AND MAXILLOFACIAL SURGEON
Credential: DMD
Phone: 309-693-1200