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General NPI Number Information
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NPI Number | 1770988594
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Entity Type | Organization
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Legal Business Name | RIVERBEND PEDIATRIC DENTISTRY, LLC
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Dates
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Enumeration Date | 10/23/2014
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Last Update Date | 10/23/2014
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Provider Practice Location Address
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Address Line | 705 KANSAS ST
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City | BETHALTO
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State | IL
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Zip | 62010-1796
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Country | US
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Telephone | 618-596-3725
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Fax |
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Provider Business Mailing Address
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Address Line | 705 KANSAS ST
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City | BETHALTO
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State | IL
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Zip | 62010-1796
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Country | US
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Telephone | 618-596-3725
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. ADAM MILES SNYDER
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Credential | DMD, MSD
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Telephone | 618-581-9201
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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 | 021002548
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License Number State | IL
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