Provider Demographics
NPI:1922598788
Name:BELLWOOD FAMILY DENTAL
Entity Type:Organization
Organization Name:BELLWOOD FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-656-0608
Mailing Address - Street 1:160 S BELLWOOD DR STE A
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-2086
Mailing Address - Country:US
Mailing Address - Phone:618-258-0239
Mailing Address - Fax:618-258-0765
Practice Address - Street 1:160 S BELLWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-2086
Practice Address - Country:US
Practice Address - Phone:618-258-0239
Practice Address - Fax:618-258-0765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028342122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty