Provider Demographics
NPI:1306212170
Name:GREEN MOUNT DENTAL, LLC
Entity Type:Organization
Organization Name:GREEN MOUNT DENTAL, LLC
Other - Org Name:PARKWAY SMILE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GUILBEAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-643-9523
Mailing Address - Street 1:1922 EDWARDSVILLE CLUB PLAZA CT
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3717
Mailing Address - Country:US
Mailing Address - Phone:618-643-9523
Mailing Address - Fax:
Practice Address - Street 1:2810 FRANK SCOTT PKWY W STE 800
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5007
Practice Address - Country:US
Practice Address - Phone:618-235-9696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty