Provider Demographics
NPI:1245579499
Name:COLANTINO, DREW ANTHONY (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:DREW
Middle Name:ANTHONY
Last Name:COLANTINO
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 ORENDORFF PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-2825
Mailing Address - Country:US
Mailing Address - Phone:217-971-3062
Mailing Address - Fax:
Practice Address - Street 1:997 CLOCK TOWER DR STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1399
Practice Address - Country:US
Practice Address - Phone:217-546-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029230122300000X
MI2901600326122300000X, 1223P0221X, 1223X0400X
IL021.0029871223P0221X
IL021.0029961223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry