Provider Demographics
NPI:1326147489
Name:MASTROIANNI, JEFFREY SCOTT (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SCOTT
Last Name:MASTROIANNI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 S. STATE ROUTE 157
Mailing Address - Street 2:SUITE 125
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1728
Mailing Address - Country:US
Mailing Address - Phone:618-288-0600
Mailing Address - Fax:618-288-8004
Practice Address - Street 1:2220 S. STATE ROUTE 157
Practice Address - Street 2:SUITE 125
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1728
Practice Address - Country:US
Practice Address - Phone:618-288-0600
Practice Address - Fax:618-288-8004
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210020181223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics