Provider Demographics
NPI:1437539350
Name:MIDWEST FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:MIDWEST FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANEY
Authorized Official - Middle Name:ELAYNE
Authorized Official - Last Name:SCHUMAN-BOYS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-654-2080
Mailing Address - Street 1:10 APEX DR STE 2
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1296
Mailing Address - Country:US
Mailing Address - Phone:618-654-2080
Mailing Address - Fax:618-654-2090
Practice Address - Street 1:10 APEX DR STE 2
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1296
Practice Address - Country:US
Practice Address - Phone:618-654-2080
Practice Address - Fax:618-654-2090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-05
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023663122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty