Provider Demographics
NPI:1326311630
Name:RESTORATION DENTAL LLC- MARSHALL DENTAL PROFESSIONALS
Entity Type:Organization
Organization Name:RESTORATION DENTAL LLC- MARSHALL DENTAL PROFESSIONALS
Other - Org Name:MARSHALL DENTAL PROFESSIONALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VILK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-348-7770
Mailing Address - Street 1:903 18TH ST.
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920
Mailing Address - Country:US
Mailing Address - Phone:217-348-7770
Mailing Address - Fax:217-349-8279
Practice Address - Street 1:815 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:IL
Practice Address - Zip Code:62441-1086
Practice Address - Country:US
Practice Address - Phone:217-826-5181
Practice Address - Fax:217-826-2651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty