MEDICARE: SMALLTOWN DENTAL GLEN 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

General Provider Information

NPI Number	:	1477148179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMALLTOWN DENTAL GLEN LLC

Provider Business Mailing Address
First Line	:	1600 S 4TH AVE STE 110
Second Line	:
City	:	MORTON
State	:	IL
Zip	:	61550-3401
Country	:	US
Telephone Number	:	309-370-5853
Fax Number	:

Provider Business Practice Location Address
First Line	:	2015 W GLEN AVE STE 230
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61614-4691
Country	:	US
Telephone Number	:	309-673-4616
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	LUKE OVERCASH
Credential	:
Telephone Number	:	309-370-5853

Provider Enumeration Date	:	03/04/2021
Last Update Date	:	03/04/2021

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