Provider Demographics
NPI:1568925014
Name:SOUTHERN ILLINOIS PEDIATRIC DENTISTRY OF EDWARDSVILLE
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS PEDIATRIC DENTISTRY OF EDWARDSVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WOHLFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-655-3272
Mailing Address - Street 1:1419 LEWIS ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025
Mailing Address - Country:US
Mailing Address - Phone:618-655-3272
Mailing Address - Fax:618-655-3273
Practice Address - Street 1:1419 LEWIS ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025
Practice Address - Country:US
Practice Address - Phone:618-655-3272
Practice Address - Fax:618-655-3273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty