Provider Demographics
NPI:1871668319
Name:DRUM, DERYL WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DERYL
Middle Name:WAYNE
Last Name:DRUM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 TAMARACK LANE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269
Mailing Address - Country:US
Mailing Address - Phone:618-628-4400
Mailing Address - Fax:618-628-4411
Practice Address - Street 1:317 TAMARACK LANE
Practice Address - Street 2:SUITE B
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269
Practice Address - Country:US
Practice Address - Phone:618-235-1241
Practice Address - Fax:618-235-7470
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021404122300000X
IL0210015651223P0221X
IL021-0015651223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1001718Medicaid