Provider Demographics
NPI:1669824439
Name:BI-STATE ORAL AND FACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:BI-STATE ORAL AND FACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:SCHLOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DMD
Authorized Official - Phone:618-462-1646
Mailing Address - Street 1:3555 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5009
Mailing Address - Country:US
Mailing Address - Phone:618-462-1646
Mailing Address - Fax:618-462-5721
Practice Address - Street 1:3555 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5009
Practice Address - Country:US
Practice Address - Phone:618-462-1646
Practice Address - Fax:618-462-5721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210027361223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1891938296Medicaid
MO1891938296Medicaid