Provider Demographics
NPI:1528187549
Name:JEFFREY S. MASTROIANNI D.M.D., M.S., P.C.
Entity Type:Organization
Organization Name:JEFFREY S. MASTROIANNI D.M.D., M.S., P.C.
Other - Org Name:MASTROIANNI ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MASTROIANNI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:618-288-0600
Mailing Address - Street 1:2220 S. STATE ROUTE 157
Mailing Address - Street 2:SUITE 125
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1728
Mailing Address - Country:US
Mailing Address - Phone:618-288-0600
Mailing Address - Fax:618-288-8004
Practice Address - Street 1:2220 S. STATE ROUTE 157
Practice Address - Street 2:SUITE 125
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1728
Practice Address - Country:US
Practice Address - Phone:618-288-0600
Practice Address - Fax:618-288-8004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190248121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty