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General NPI Number Information
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NPI Number | 1568925014
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Entity Type | Organization
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Legal Business Name | SOUTHERN ILLINOIS PEDIATRIC DENTISTRY OF EDWARDSVILLE
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Dates
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Enumeration Date | 04/11/2019
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Last Update Date | 04/11/2019
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Provider Practice Location Address
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Address Line | 1419 LEWIS ROAD SUITE 2
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City | EDWARDSVILLE
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State | IL
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Zip | 62025
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Country | US
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Telephone | 618-655-3272
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Fax | 618-655-3273
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Provider Business Mailing Address
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Address Line | 1419 LEWIS ROAD SUITE 2
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City | EDWARDSVILLE
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State | IL
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Zip | 62025
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Country | US
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Telephone | 618-655-3272
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Fax | 618-655-3273
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Authorized Official
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Title or Position | DENTIST/MEMBER
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Name | DR. CHRISTINE ANNE WOHLFORD
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Credential | DMD
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Telephone | 618-655-3272
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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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