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General NPI Number Information
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NPI Number | 1386414290
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Entity Type | Organization
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Legal Business Name | JERSEYVILLE DENTAL GROUP LLC
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Dates
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Enumeration Date | 01/03/2024
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Last Update Date | 01/03/2024
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Provider Practice Location Address
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Address Line | 105 S STATE ST
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City | JERSEYVILLE
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State | IL
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Zip | 62052-1850
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Country | US
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Telephone | 618-498-5822
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Fax | 618-498-5822
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Provider Business Mailing Address
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Address Line | 105 S STATE ST
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City | JERSEYVILLE
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State | IL
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Zip | 62052-1850
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Country | US
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Telephone | 618-498-5822
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Fax | 618-498-5822
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS/ACQUISITIONS
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Name | DIANA LIFRITZ
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Credential |
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Telephone | 618-873-7500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 |
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