Provider Demographics
NPI:1700035730
Name:PREVILLE, MEGAN LYNETTE (DMD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:LYNETTE
Last Name:PREVILLE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 BOND AVE
Mailing Address - Street 2:DENTAL CLINIC
Mailing Address - City:CENTREVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62207-2328
Mailing Address - Country:US
Mailing Address - Phone:618-332-2740
Mailing Address - Fax:
Practice Address - Street 1:6000 BOND AVE
Practice Address - Street 2:DENTAL CLINIC
Practice Address - City:CENTREVILLE
Practice Address - State:IL
Practice Address - Zip Code:62207-2328
Practice Address - Country:US
Practice Address - Phone:618-332-2740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3187122300000X
390200000X
IL019029730122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program