Provider Demographics
NPI:1790799385
Name:JAIN, POONAM (BDS, MS)
Entity Type:Individual
Prefix:DR
First Name:POONAM
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:BDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:IL
Mailing Address - Zip Code:62088-2217
Mailing Address - Country:US
Mailing Address - Phone:618-208-1622
Mailing Address - Fax:
Practice Address - Street 1:24 GINGER CREEK PKWY
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3502
Practice Address - Country:US
Practice Address - Phone:618-692-1110
Practice Address - Fax:618-692-1112
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice