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General NPI Number Information
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NPI Number | 1932479235
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Entity Type | Organization
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Legal Business Name | PREMIER DENTAL OF MT VERNON PC
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Dates
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Enumeration Date | 01/04/2012
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Last Update Date | 01/04/2012
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Provider Practice Location Address
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Address Line | 9 CUSUMANO PROFESSIONAL PLAZA DR
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City | MOUNT VERNON
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State | IL
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Zip | 62864-6736
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Country | US
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Telephone | 618-315-6213
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1003
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City | MOUNT VERNON
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State | IL
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Zip | 62864-0021
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Country | US
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Telephone | 618-315-6213
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/DENTIST
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Name | DR. CARLA GEHA
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Credential | DMD
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Telephone | 618-315-6213
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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 | 019028108
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License Number State | IL
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