Provider Demographics
NPI:1700920113
Name:KING, ORDIE H JR (DDS, PHD)
Entity Type:Individual
Prefix:
First Name:ORDIE
Middle Name:H
Last Name:KING
Suffix:JR
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1166
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-1166
Mailing Address - Country:US
Mailing Address - Phone:618-466-3645
Mailing Address - Fax:618-466-3410
Practice Address - Street 1:6111 VOLLMER LN
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1062
Practice Address - Country:US
Practice Address - Phone:618-466-3645
Practice Address - Fax:618-466-3410
Is Sole Proprietor?:No
Enumeration Date:2007-02-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL67299Medicare UPIN