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General NPI Number Information
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NPI Number | 1255959847
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Entity Type | Individual
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Provider Name | KATELYN CECELIA GENENBACHER DMD
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Gender | Female
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Dates
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Enumeration Date | 07/09/2020
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Last Update Date | 07/09/2020
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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 | 2330 S 48TH ST
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City | QUINCY
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State | IL
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Zip | 62305-6097
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Country | US
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Telephone | 217-617-6794
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019032754
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License Number State | IL
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