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General NPI Number Information
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NPI Number | 1285377036
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Entity Type | Organization
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Legal Business Name | LITTLE EGYPT PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 04/19/2022
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Last Update Date | 04/19/2022
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Provider Practice Location Address
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Address Line | 1255 CEDAR CT
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City | CARBONDALE
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State | IL
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Zip | 62901-5335
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Country | US
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Telephone | 618-319-4536
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Fax |
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Provider Business Mailing Address
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Address Line | 1255 CEDAR CT
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City | CARBONDALE
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State | IL
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Zip | 62901-5335
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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 | OWNER
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Name | TRAVIS CRIPPS
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Credential |
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Telephone | 618-694-2110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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