Provider Demographics
NPI:1669540399
Name:CENTRAL ILLINOIS ORAL AND MAXILLOFACIAL SURGERY, PC
Entity type:Organization
Organization Name:CENTRAL ILLINOIS ORAL AND MAXILLOFACIAL SURGERY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:KROEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:14 E ANTHONY DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-2748
Mailing Address - Country:US
Mailing Address - Phone:217-355-2809
Mailing Address - Fax:217-355-5921
Practice Address - Street 1:14 E ANTHONY DR
Practice Address - Street 2:SUITE C
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-2748
Practice Address - Country:US
Practice Address - Phone:217-355-2809
Practice Address - Fax:217-355-5921
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL ILLINOIS ORAL AND MAXILLOFACIAL SURGERY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-01
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty