Provider Demographics
NPI:1972762367
Name:RONALD WEEMS JR P.C.
Entity Type:Organization
Organization Name:RONALD WEEMS JR P.C.
Other - Org Name:WOOD RIVER FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-259-2007
Mailing Address - Street 1:26 GINGER CREEK PKWY
Mailing Address - Street 2:PO BOX 430
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-3502
Mailing Address - Country:US
Mailing Address - Phone:618-288-6201
Mailing Address - Fax:618-288-6452
Practice Address - Street 1:1915 VAUGHN ROAD
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095
Practice Address - Country:US
Practice Address - Phone:618-259-2007
Practice Address - Fax:618-259-2675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190251591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty