MEDICARE: LEWIS AND CLARK COMMUNITY COLLEGE

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	122300000X	Dentist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497746077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEWIS AND CLARK COMMUNITY COLLEGE

Provider Business Mailing Address
First Line	:	5800 GODFREY RD
Second Line	:
City	:	GODFREY
State	:	IL
Zip	:	62035-2466
Country	:	US
Telephone Number	:	618-468-4463
Fax Number	:	618-468-4408

Provider Business Practice Location Address
First Line	:	5800 GODFREY RD
Second Line	:
City	:	GODFREY
State	:	IL
Zip	:	62035-2466
Country	:	US
Telephone Number	:	618-468-4463
Fax Number	:	618-468-4408

Authorized Official
Title or Position	:	CLINIC SUPERVISOR
Name	:	DR. JOHN RANDALL MILLER
Credential	:	D.D.S.
Telephone Number	:	618-468-4414

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	08/22/2020

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Directions to “LEWIS AND CLARK COMMUNITY COLLEGE ” Practice Location

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