Provider Demographics
NPI:1114198744
Name:SARAH BUSH LINCOLN DENTAL SERVICES
Entity Type:Organization
Organization Name:SARAH BUSH LINCOLN DENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PLUARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-258-2102
Mailing Address - Street 1:225 RICHMOND AVE E STE B
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4651
Mailing Address - Country:US
Mailing Address - Phone:217-235-0800
Mailing Address - Fax:217-235-0801
Practice Address - Street 1:225 RICHMOND AVE E STE B
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4651
Practice Address - Country:US
Practice Address - Phone:217-235-0800
Practice Address - Fax:217-235-0801
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SARAH BUSH LINCOLN HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-24
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid