Provider Demographics
NPI:1124285317
Name:MATTOON DENTAL PC
Entity type:Organization
Organization Name:MATTOON DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:G
Authorized Official - Last Name:YOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-235-0434
Mailing Address - Street 1:PO BOX 1217
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938
Mailing Address - Country:US
Mailing Address - Phone:217-235-0434
Mailing Address - Fax:217-234-3418
Practice Address - Street 1:225 RICHMOND AVE E
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938
Practice Address - Country:US
Practice Address - Phone:217-235-0434
Practice Address - Fax:217-234-3418
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MATTOON DENTAL PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020918122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty