Healthcare Provider Details

I. General information

NPI: 1881280030
Provider Name (Legal Business Name): OWEN DENTAL, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 N MAIN ST
SMITHTON IL
62285-1518
US

IV. Provider business mailing address

8808 WHEAT DR
TROY IL
62294-2272
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-9012
  • Fax: 618-233-2399
Mailing address:
  • Phone: 618-406-0965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JON OWEN
Title or Position: PRESIDENT/DENTIST
Credential: DMD
Phone: 618-406-0965