=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013570928
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARCH VIEW FAMILY DENTAL, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2019
-----------------------------------------------------
Last Update Date | 04/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2133 S STATE ROUTE 157
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62025-3691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-656-2006
-----------------------------------------------------
Fax | 618-656-2066
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2133 S STATE ROUTE 157
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62025-3691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-656-2006
-----------------------------------------------------
Fax | 618-656-2066
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMIN
-----------------------------------------------------
Name | ANDREA MARIE YORK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-335-0430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------