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General NPI Number Information
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NPI Number | 1285094862
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Entity Type | Organization
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Legal Business Name | JEFFREY S. MASTROIANNI, D.M.D., M.S.
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Dates
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Enumeration Date | 02/25/2016
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Last Update Date | 02/25/2016
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Provider Practice Location Address
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Address Line | 2220 S STATE ROUTE 157 SUITE 125
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City | GLEN CARBON
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State | IL
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Zip | 62034-1724
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Country | US
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Telephone | 618-288-0600
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Fax | 618-288-8004
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Provider Business Mailing Address
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Address Line | 2220 S STATE ROUTE 157 SUITE 125
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City | GLEN CARBON
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State | IL
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Zip | 62034-1724
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Country | US
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Telephone | 618-288-0600
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Fax | 618-288-8004
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Authorized Official
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Title or Position | CEO
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Name | DR. JEFFREY MASTROIANNI
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Credential | D.M.D.
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Telephone | 618-288-0600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 21002018
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License Number State | IL
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