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General NPI Number Information
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NPI Number | 1538180617
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Entity Type | Organization
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Legal Business Name | SOUTHERN ILLINOIS ORAL & MAXILLOFACIAL SURGERY, LTD.
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Dates
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Enumeration Date | 07/22/2006
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Last Update Date | 11/24/2014
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Provider Practice Location Address
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Address Line | 2900 FRANK SCOTT PKWY W SUITE 960
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City | BELLEVILLE
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State | IL
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Zip | 62223-5000
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Country | US
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Telephone | 618-233-8080
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Fax | 618-233-1192
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Provider Business Mailing Address
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Address Line | 2900 FRANK SCOTT PKWY W SUITE 960
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City | BELLEVILLE
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State | IL
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Zip | 62223-5000
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Country | US
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Telephone | 618-233-8080
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Fax | 618-233-1192
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL R. HESTERBERG
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Credential | D.M.D.
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Telephone | 618-233-8080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 021-001364
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License Number State | IL
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