Provider Demographics
NPI:1255959847
Name:GENENBACHER, KATELYN CECELIA (DMD)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:CECELIA
Last Name:GENENBACHER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-6097
Mailing Address - Country:US
Mailing Address - Phone:217-617-6794
Mailing Address - Fax:
Practice Address - Street 1:101 UNITED DR STE 150
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-7439
Practice Address - Country:US
Practice Address - Phone:618-345-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190327541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice