Provider Demographics
NPI:1174945158
Name:STONE FALLS DENTAL CARE, LLC
Entity type:Organization
Organization Name:STONE FALLS DENTAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLEIGH
Authorized Official - Middle Name:
Authorized Official - Last Name:PRANE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-624-2800
Mailing Address - Street 1:4945 STONE FALLS CTR
Mailing Address - Street 2:SUITE A
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7801
Mailing Address - Country:US
Mailing Address - Phone:618-624-2800
Mailing Address - Fax:618-551-2288
Practice Address - Street 1:4945 STONE FALLS CTR
Practice Address - Street 2:SUITE A
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-7801
Practice Address - Country:US
Practice Address - Phone:618-624-2800
Practice Address - Fax:618-551-2288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-10
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
IL19026282122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty