Provider Demographics
NPI:1457887168
Name:SHAWNEE HILLS ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:SHAWNEE HILLS ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:METRO OMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:BURTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-288-8770
Mailing Address - Street 1:2246 S STATE ROUTE 157
Mailing Address - Street 2:SUITE 325
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1717
Mailing Address - Country:US
Mailing Address - Phone:618-288-8770
Mailing Address - Fax:618-288-8782
Practice Address - Street 1:2246 S STATE ROUTE 157
Practice Address - Street 2:SUITE 325
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1717
Practice Address - Country:US
Practice Address - Phone:618-288-8770
Practice Address - Fax:618-288-8782
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAWNEE HILLS ORAL & MAXILLOFACIAL SURGERY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190261241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty