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General NPI Number Information
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NPI Number | 1346552247
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Entity Type | Organization
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Legal Business Name | CHESTER SMILE CENTER
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Dates
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Enumeration Date | 07/08/2010
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Last Update Date | 07/08/2010
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Provider Practice Location Address
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Address Line | 1101 OPDYKE ST
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City | CHESTER
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State | IL
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Zip | 62233-2004
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Country | US
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Telephone | 618-826-4440
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Fax | 618-826-5799
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Provider Business Mailing Address
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Address Line | 1101 OPDYKE ST
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City | CHESTER
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State | IL
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Zip | 62233-2004
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Country | US
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Telephone | 618-826-4440
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Fax | 618-826-5799
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. MICHAEL PETER HOLUB
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Credential | D.D.S.
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Telephone | 618-826-4440
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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 | 019022619
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License Number State | IL
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