Provider Demographics
NPI:1962674788
Name:SOUTHERN ILLINOIS UNIVERSITY CARBONDALE
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS UNIVERSITY CARBONDALE
Other - Org Name:COMMUNITY DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CRIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-453-2353
Mailing Address - Street 1:1365 DOUGLAS DRIVE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901
Mailing Address - Country:US
Mailing Address - Phone:618-453-2353
Mailing Address - Fax:
Practice Address - Street 1:1365 DOUGLAS DRIVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-453-2353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN ILLINOIS UNIVERSITY CARBONDALE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-01
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019024395261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1184615866Medicaid
IL019.032439Medicaid
IL1295716959Medicaid
IL1023008364Medicaid