Provider Demographics
NPI:1053582189
Name:SOUTHERN ILLINOIS UNIVERSITY CARBONDALE DENTAL SEALANT PROGRAM
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS UNIVERSITY CARBONDALE DENTAL SEALANT PROGRAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DSGP PROGRAM COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:R
Authorized Official - Last Name:KREID
Authorized Official - Suffix:
Authorized Official - Credentials:RDH, PHDH, BSDH
Authorized Official - Phone:618-453-8823
Mailing Address - Street 1:1365 DOUGLAS DR RM 18
Mailing Address - Street 2:CASA, SAH, MC 6615
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2583
Mailing Address - Country:US
Mailing Address - Phone:618-453-7211
Mailing Address - Fax:618-453-7020
Practice Address - Street 1:1365 DOUGLAS DR RM 18
Practice Address - Street 2:CASA, SAH, MC 6615
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2583
Practice Address - Country:US
Practice Address - Phone:618-453-7211
Practice Address - Fax:618-453-7020
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN ILLINOIS UNIVERSITY CARBONDALE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-17
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental