MEDICARE: CAULKS HILL DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2000174030	MO

General Provider Information

NPI Number	:	1417383852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAULKS HILL DENTAL LLC

Provider Business Mailing Address
First Line	:	1922 EDWARDSVILLE CLUB PLAZA CT
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-3717
Country	:	US
Telephone Number	:	618-248-2038
Fax Number	:

Provider Business Practice Location Address
First Line	:	1319 CAULKS HILL RD
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63304-6863
Country	:	US
Telephone Number	:	636-441-3430
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DAVID GUILBEAULT
Credential	:	DMD
Telephone Number	:	636-441-3430

Provider Enumeration Date	:	09/17/2013
Last Update Date	:	05/28/2015

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