Provider Demographics
NPI:1386194876
Name:DENTAL WELLNESS CENTER OF MARYVILLE LTD
Entity Type:Organization
Organization Name:DENTAL WELLNESS CENTER OF MARYVILLE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-288-1923
Mailing Address - Street 1:2933 MARYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5400
Mailing Address - Country:US
Mailing Address - Phone:618-288-1923
Mailing Address - Fax:
Practice Address - Street 1:2933 MARYVILLE RD
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5400
Practice Address - Country:US
Practice Address - Phone:618-288-1923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-07
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty