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General NPI Number Information
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NPI Number | 1275663338
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Entity Type | Organization
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Legal Business Name | ORAL & MAXILLOFACIAL SURGEONS OF CENTRAL ILLINOIS
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Dates
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Enumeration Date | 03/07/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 5009 A EXECUTIVE DR
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City | PEORIA
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State | IL
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Zip | 61614-4866
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Country | US
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Telephone | 309-693-1200
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Fax | 309-693-9998
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Provider Business Mailing Address
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Address Line | 5009 A EXECUTIVE DRIVE
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City | PEORIA
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State | IL
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Zip | 61614-4866
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Country | US
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Telephone | 309-693-1200
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Fax | 309-693-9998
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Authorized Official
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Title or Position | ORAL AND MAXILLOFACIAL SURGEON
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Name | DR. ROBERT WILLIAM YOUNG
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Credential | DMD
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Telephone | 309-693-1200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State | IL
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Taxonomy #2
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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 | IL
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