Provider Demographics
NPI:1750390373
Name:BELLWOOD FAMILY DENTISTRY
Entity type:Organization
Organization Name:BELLWOOD FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-258-0028
Mailing Address - Street 1:321 N BELLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-2038
Mailing Address - Country:US
Mailing Address - Phone:618-258-0028
Mailing Address - Fax:618-258-1060
Practice Address - Street 1:321 N BELLWOOD DR
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-2038
Practice Address - Country:US
Practice Address - Phone:618-258-0028
Practice Address - Fax:618-258-1060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty