Provider Demographics
NPI:1093170003
Name:MIDAMERICA CENTER FOR DENTAL WELLNESS & AESTHETICS PC
Entity Type:Organization
Organization Name:MIDAMERICA CENTER FOR DENTAL WELLNESS & AESTHETICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:BRUNK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-283-2929
Mailing Address - Street 1:607 W ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1234
Mailing Address - Country:US
Mailing Address - Phone:618-283-2929
Mailing Address - Fax:618-283-2113
Practice Address - Street 1:607 W ORCHARD ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1234
Practice Address - Country:US
Practice Address - Phone:618-283-2929
Practice Address - Fax:618-283-2113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190191071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty