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General NPI Number Information
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NPI Number | 1235876814
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Entity Type | Organization
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Legal Business Name | DENTAL PROFESSIONALS OF ILLINOIS, P.C.
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Dates
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Enumeration Date | 05/16/2022
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Last Update Date | 07/14/2022
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Provider Practice Location Address
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Address Line | 101 UNITED DR STE 150
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City | COLLINSVILLE
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State | IL
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Zip | 62234-7439
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Country | US
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Telephone | 618-345-7676
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Fax |
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Provider Business Mailing Address
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Address Line | 101 UNITED DR STE 150
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City | COLLINSVILLE
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State | IL
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Zip | 62234-7439
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | COURTNEY MONTEITH
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Credential |
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Telephone | 214-540-8306
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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 |
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License Number State |
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