Provider Demographics
NPI:1720250939
Name:SOUTHERN ILLINOIS UNIVERSITY CARBONDALE
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS UNIVERSITY CARBONDALE
Other - Org Name:ILLINOIS CHILDREN'S HEALTHCARE FOUNDATION DENTAL GRANT PROJECT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOC. PROF./DENTAL HYGIENE PROGRAM
Authorized Official - Prefix:MRS
Authorized Official - First Name:RONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMATTEI
Authorized Official - Suffix:
Authorized Official - Credentials:RDH, PHD
Authorized Official - Phone:618-453-7298
Mailing Address - Street 1:1365 DOUGLAS DR
Mailing Address - Street 2:COLLEGE OF APPLIED SCIENCES/SCHOOL OF ALLIED HEALTH
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-6615
Mailing Address - Country:US
Mailing Address - Phone:618-453-7241
Mailing Address - Fax:618-453-7020
Practice Address - Street 1:1365 DOUGLAS DR
Practice Address - Street 2:COLLEGE OF APPLIED SCIENCES/SCHOOL OF ALLIED HEALTH
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-6615
Practice Address - Country:US
Practice Address - Phone:618-453-7241
Practice Address - Fax:618-453-7020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental