Provider Demographics
NPI:1851540330
Name:CENTRAL ILLINOIS ORAL AND MAXIOFACIAL SURGERY, PC
Entity Type:Organization
Organization Name:CENTRAL ILLINOIS ORAL AND MAXIOFACIAL SURGERY, PC
Other - Org Name:DR. FIRAS ALI, DMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDIEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:14 E ANTHONY DR STE C
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-2749
Mailing Address - Country:US
Mailing Address - Phone:217-355-2809
Mailing Address - Fax:217-355-5921
Practice Address - Street 1:14 E ANTHONY DR STE C
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-2749
Practice Address - Country:US
Practice Address - Phone:217-355-2809
Practice Address - Fax:217-355-5921
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL ILLINOIS ORAL AND MAXIOFACIAL SURGERY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-09
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty