Provider Demographics
NPI:1770755852
Name:DENTAL SEALANTS & MORE
Entity type:Organization
Organization Name:DENTAL SEALANTS & MORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:309-339-4433
Mailing Address - Street 1:2126 N. UNIVERSITY ST.
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604
Mailing Address - Country:US
Mailing Address - Phone:309-339-4433
Mailing Address - Fax:309-406-1326
Practice Address - Street 1:2126 N. UNIVERSITY ST.
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604
Practice Address - Country:US
Practice Address - Phone:309-339-4433
Practice Address - Fax:309-406-1326
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL SEALANTS & MORE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-28
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-010639122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1001319OtherDORAL DENTAL OF ILLINOIS