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General NPI Number Information
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NPI Number | 1124285317
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Entity Type | Organization
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Legal Business Name | MATTOON DENTAL PC
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Dates
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Enumeration Date | 05/16/2008
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Last Update Date | 05/16/2008
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Provider Practice Location Address
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Address Line | 225 RICHMOND AVE E
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City | MATTOON
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State | IL
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Zip | 61938
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Country | US
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Telephone | 217-235-0434
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Fax | 217-234-3418
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Provider Business Mailing Address
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Address Line | PO BOX 1217
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City | MATTOON
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State | IL
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Zip | 61938
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Country | US
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Telephone | 217-235-0434
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Fax | 217-234-3418
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Authorized Official
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Title or Position | DENTIST OWNER
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Name | DR. GREGORY G YOUNT
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Credential | DMD
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Telephone | 217-235-0434
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019020918
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License Number State | IL
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