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General NPI Number Information
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NPI Number | 1477214484
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Entity Type | Organization
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Legal Business Name | SMALLTOWN DENTAL CHILLICOTHE LLC
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Dates
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Enumeration Date | 01/03/2022
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Last Update Date | 01/03/2022
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Provider Practice Location Address
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Address Line | 1008 N 4TH ST STE B
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City | CHILLICOTHEE
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State | IL
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Zip | 61523-1574
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Country | US
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Telephone | 309-274-3820
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Fax |
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Provider Business Mailing Address
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Address Line | 17471 MOORE RD
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City | MORTON
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State | IL
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Zip | 61550-9222
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Country | US
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Telephone | 309-370-5853
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Fax |
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Authorized Official
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Title or Position | CIO
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Name | LUKE OVERCASH
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Credential |
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Telephone | 309-370-5853
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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 |
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License Number State |
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