Provider Demographics
NPI:1790799385
Name:JAIN, POONAM
Entity type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:IL
Mailing Address - Zip Code:62088-2217
Mailing Address - Country:US
Mailing Address - Phone:618-978-1847
Mailing Address - Fax:
Practice Address - Street 1:109 W MAIN ST
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:IL
Practice Address - Zip Code:62088-1452
Practice Address - Country:US
Practice Address - Phone:618-635-2280
Practice Address - Fax:618-635-2902
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0249691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice