Provider Demographics
NPI:1770632119
Name:SMICHAEL VANCIL DMD LLC
Entity Type:Organization
Organization Name:SMICHAEL VANCIL DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:S
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:VANCIL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-529-3931
Mailing Address - Street 1:1255 CEDAR COURT
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5335
Mailing Address - Country:US
Mailing Address - Phone:618-529-3931
Mailing Address - Fax:618-529-1011
Practice Address - Street 1:1255 CEDAR COURT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5335
Practice Address - Country:US
Practice Address - Phone:618-529-3931
Practice Address - Fax:618-529-1011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190172931223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty