Provider Demographics
NPI:1346546421
Name:CENTRAL ILLINOIS CENTER FOR TMJ AND FACIAL PAIN, P.C.
Entity Type:Organization
Organization Name:CENTRAL ILLINOIS CENTER FOR TMJ AND FACIAL PAIN, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:WALZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-699-1300
Mailing Address - Street 1:731 SABRINA DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-3581
Mailing Address - Country:US
Mailing Address - Phone:309-699-1300
Mailing Address - Fax:
Practice Address - Street 1:731 SABRINA DR
Practice Address - Street 2:SUITE A
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-3581
Practice Address - Country:US
Practice Address - Phone:309-699-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-07
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021995122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU10110Medicare UPIN
IL939740Medicare PIN