Healthcare Provider Details

I. General information

NPI: 1073444196
Provider Name (Legal Business Name): STEVEN DANIEL ALDRIDGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6665 STATE ROUTE 146 E
VIENNA IL
62995-3122
US

IV. Provider business mailing address

6665 STATE ROUTE 146 E
VIENNA IL
62995-3122
US

V. Phone/Fax

Practice location:
  • Phone: 618-658-8331
  • Fax: 618-658-4027
Mailing address:
  • Phone: 618-658-8331
  • Fax: 618-658-4027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019022123
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: