Provider Demographics
NPI:1619425337
Name:JAMES E LILLENBERG DDS INC
Entity Type:Organization
Organization Name:JAMES E LILLENBERG DDS INC
Other - Org Name:JAMES E LILLENBERG DDS INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:LILLENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-842-0256
Mailing Address - Street 1:11428 TESSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-6925
Mailing Address - Country:US
Mailing Address - Phone:314-842-0256
Mailing Address - Fax:314-842-0259
Practice Address - Street 1:11428 TESSON FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-6925
Practice Address - Country:US
Practice Address - Phone:314-842-0256
Practice Address - Fax:314-842-0259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-12
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO012959305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service