Healthcare Provider Details

I. General information

NPI: 1245579499
Provider Name (Legal Business Name): DREW ANTHONY COLANTINO DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2013
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

997 CLOCK TOWER DR STE B
SPRINGFIELD IL
62704-1399
US

IV. Provider business mailing address

1212 ORENDORFF PKWY
SPRINGFIELD IL
62704-2825
US

V. Phone/Fax

Practice location:
  • Phone: 217-546-9600
  • Fax:
Mailing address:
  • Phone: 217-971-3062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019029230
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901600326
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number021.002987
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2901600326
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901600326
License Number StateMI
# 6
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021.002996
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: