Provider Demographics
NPI:1497925184
Name:JEANINE HUDDLESTUN-JOHNS D.D.S.
Entity Type:Organization
Organization Name:JEANINE HUDDLESTUN-JOHNS D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HUDDLESTUN-JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:618-783-3714
Mailing Address - Street 1:605 SOUTH VANBUREN
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IL
Mailing Address - Zip Code:62448
Mailing Address - Country:US
Mailing Address - Phone:618-783-3714
Mailing Address - Fax:618-783-3294
Practice Address - Street 1:605 SOUTH VANBUREN
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IL
Practice Address - Zip Code:62448
Practice Address - Country:US
Practice Address - Phone:618-783-3714
Practice Address - Fax:618-783-3294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180942Medicaid
IL101119Medicaid