=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932814720
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT RIVERS DENTAL P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2023
-----------------------------------------------------
Last Update Date | 01/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 708 E BETHALTO DR
-----------------------------------------------------
City | BETHALTO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62010-1871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-377-0044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 708 E BETHALTO DR
-----------------------------------------------------
City | BETHALTO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62010-1871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-377-0044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MATTHEW JAMES MCCULLOUGH
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 618-339-7248
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------