Provider Demographics
NPI:1659957850
Name:SIU DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:SIU DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-474-7104
Mailing Address - Street 1:2800 COLLEGE AVE
Mailing Address - Street 2:BLDG 273
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4700
Mailing Address - Country:US
Mailing Address - Phone:618-474-7100
Mailing Address - Fax:618-474-7150
Practice Address - Street 1:195 UNIVERSITY PARK DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3645
Practice Address - Country:US
Practice Address - Phone:618-650-5781
Practice Address - Fax:618-650-5790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty