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General NPI Number Information
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NPI Number | 1770755852
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Entity Type | Organization
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Legal Business Name | DENTAL SEALANTS & MORE
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Dates
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Enumeration Date | 03/28/2008
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Last Update Date | 02/08/2017
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Provider Practice Location Address
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Address Line | 2126 N. UNIVERSITY ST.
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City | PEORIA
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State | IL
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Zip | 61604
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Country | US
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Telephone | 309-339-4433
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Fax | 309-406-1326
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Provider Business Mailing Address
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Address Line | 2126 N. UNIVERSITY ST.
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City | PEORIA
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State | IL
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Zip | 61604
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Country | US
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Telephone | 309-339-4433
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Fax | 309-406-1326
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Authorized Official
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Title or Position | PRESIDENT
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Name | RENEE KATHERINE DIETZ
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Credential | DMD
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Telephone | 309-339-4433
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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 | 019-010639
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License Number State | IL
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