Provider Demographics
NPI:1932479235
Name:PREMIER DENTAL OF MT VERNON PC
Entity Type:Organization
Organization Name:PREMIER DENTAL OF MT VERNON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GEHA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-315-6213
Mailing Address - Street 1:PO BOX 1003
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-0021
Mailing Address - Country:US
Mailing Address - Phone:618-315-6213
Mailing Address - Fax:
Practice Address - Street 1:9 CUSUMANO PROFESSIONAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6736
Practice Address - Country:US
Practice Address - Phone:618-315-6213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028108122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty