Provider Demographics
NPI:1609288521
Name:BELLEVILLE DENTAL CENTER
Entity Type:Organization
Organization Name:BELLEVILLE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:
Authorized Official - Last Name:ENGELAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-233-3503
Mailing Address - Street 1:3503 N BELT W
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5959
Mailing Address - Country:US
Mailing Address - Phone:618-233-3503
Mailing Address - Fax:
Practice Address - Street 1:3503 N BELT W
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5959
Practice Address - Country:US
Practice Address - Phone:618-233-3503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19015709122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
788754OtherUNITED CONCORDIA