Provider Demographics
NPI:1346410156
Name:THE FAMILY DENTAL CENTER OF PINCKNEYVILLE
Entity Type:Organization
Organization Name:THE FAMILY DENTAL CENTER OF PINCKNEYVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-357-9333
Mailing Address - Street 1:212 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:PINCKNEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62274-1015
Mailing Address - Country:US
Mailing Address - Phone:618-357-9333
Mailing Address - Fax:
Practice Address - Street 1:212 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:PINCKNEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62274-1015
Practice Address - Country:US
Practice Address - Phone:618-357-9333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019019032122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty