Provider Demographics
NPI:1801000443
Name:CENTER FOR ORAL AND MAXILLOFACIAL SURGERY, P.C.
Entity Type:Organization
Organization Name:CENTER FOR ORAL AND MAXILLOFACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL & MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:618-387-2464
Mailing Address - Street 1:10200 WEST MAIN
Mailing Address - Street 2:SIGNAL HILL MEDICAL BLDG
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223
Mailing Address - Country:US
Mailing Address - Phone:618-397-2464
Mailing Address - Fax:618-398-4450
Practice Address - Street 1:10200 W MAIN ST
Practice Address - Street 2:SIGNAL HILL MEDICAL BLDG
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-1408
Practice Address - Country:US
Practice Address - Phone:618-397-2464
Practice Address - Fax:618-398-4450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060000298204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216016Medicare UPIN