Healthcare Provider Details

I. General information

NPI: 1316595101
Provider Name (Legal Business Name): TEUTOPOLIS FAMILY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 N PEARL ST
TEUTOPOLIS IL
62467-1134
US

IV. Provider business mailing address

522 E JASPER ST
PARIS IL
61944-2437
US

V. Phone/Fax

Practice location:
  • Phone: 217-857-3201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: BLAKE WESTRA
Title or Position: OWNER
Credential: DMD
Phone: 217-463-4110