Provider Demographics
NPI:1699365809
Name:SMALLTOWN DENTAL WILLOW KNOLLS LLC
Entity Type:Organization
Organization Name:SMALLTOWN DENTAL WILLOW KNOLLS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:OVERCASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-370-5853
Mailing Address - Street 1:6712 N MOUNTELLO DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2328
Mailing Address - Country:US
Mailing Address - Phone:309-691-7855
Mailing Address - Fax:
Practice Address - Street 1:6712 N MOUNTELLO DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2328
Practice Address - Country:US
Practice Address - Phone:309-691-7855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SMALLTOWN DENTAL MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty