Provider Demographics
NPI:1558484410
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:DR
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:618-797-9940
Mailing Address - Street 1:3120 MARYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-5119
Mailing Address - Country:US
Mailing Address - Phone:618-797-9940
Mailing Address - Fax:
Practice Address - Street 1:3120 MARYVILLE RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-5119
Practice Address - Country:US
Practice Address - Phone:618-797-9940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-07
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-023663122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty