Provider Demographics
NPI:1497746077
Name:LEWIS AND CLARK COMMUNITY COLLEGE
Entity Type:Organization
Organization Name:LEWIS AND CLARK COMMUNITY COLLEGE
Other - Org Name:LEWIS AND CLARK COMMUNITY COLLEGE DENTAL HYGIENE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC SUPERVISOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:618-468-4414
Mailing Address - Street 1:5800 GODFREY RD
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-2466
Mailing Address - Country:US
Mailing Address - Phone:618-468-4463
Mailing Address - Fax:618-468-4408
Practice Address - Street 1:5800 GODFREY RD
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-2466
Practice Address - Country:US
Practice Address - Phone:618-468-4463
Practice Address - Fax:618-468-4408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9176253Medicaid