Provider Demographics
NPI:1275663338
Name:ORAL & MAXILLOFACIAL SURGEONS OF CENTRAL ILLINOIS
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGEONS OF CENTRAL ILLINOIS
Other - Org Name:DR ROBERT W YOUNG
Other - Org Type:Other Name
Authorized Official - Title/Position:ORAL AND MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:309-693-1200
Mailing Address - Street 1:5009 A EXECUTIVE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4866
Mailing Address - Country:US
Mailing Address - Phone:309-693-1200
Mailing Address - Fax:309-693-9998
Practice Address - Street 1:5009 A EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4866
Practice Address - Country:US
Practice Address - Phone:309-693-1200
Practice Address - Fax:309-693-9998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty