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General NPI Number Information
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NPI Number | 1598408783
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Entity Type | Organization
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Legal Business Name | THE DENTAL STUDIO OF SOUTHERN ILLINOIS
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Dates
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Enumeration Date | 04/15/2022
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Last Update Date | 05/01/2022
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Provider Practice Location Address
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Address Line | 741 W STATE ST STE 1
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City | O FALLON
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State | IL
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Zip | 62269-1971
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Country | US
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Telephone | 618-632-2282
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Fax |
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Provider Business Mailing Address
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Address Line | 741 W STATE ST STE 1
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City | O FALLON
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State | IL
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Zip | 62269-1971
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | BRITTANY GILBRETH
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Credential |
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Telephone | 618-304-0998
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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