Provider Demographics
NPI:1417221532
Name:LINCOLN PLACE DENTAL PC
Entity Type:Organization
Organization Name:LINCOLN PLACE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:DORTCH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-257-9189
Mailing Address - Street 1:114 LINCOLN PLACE CT
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5884
Mailing Address - Country:US
Mailing Address - Phone:618-257-9189
Mailing Address - Fax:618-257-9253
Practice Address - Street 1:114 LINCOLN PLACE CT
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5884
Practice Address - Country:US
Practice Address - Phone:618-257-9189
Practice Address - Fax:618-257-9253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190162871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty