Provider Demographics
NPI:1750609418
Name:GRANITE CITY DENTAL CARE LTD
Entity type:Organization
Organization Name:GRANITE CITY DENTAL CARE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LA NAE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-351-2650
Mailing Address - Street 1:2130 JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-3961
Mailing Address - Country:US
Mailing Address - Phone:618-877-0780
Mailing Address - Fax:618-877-8450
Practice Address - Street 1:2102 N MARKET ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1306
Practice Address - Country:US
Practice Address - Phone:618-877-0780
Practice Address - Fax:618-877-8450
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANITE CITY DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0225511122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty