Provider Demographics
NPI:1841449329
Name:CENTRAL ILLINOIS ORAL AND MAXIOFACIAL SURGERY, PC
Entity type:Organization
Organization Name:CENTRAL ILLINOIS ORAL AND MAXIOFACIAL SURGERY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDIEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:2633 CHATHAM RD STE A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4185
Mailing Address - Country:US
Mailing Address - Phone:217-698-8777
Mailing Address - Fax:217-698-8787
Practice Address - Street 1:2633 CHATHAM RD STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4185
Practice Address - Country:US
Practice Address - Phone:217-698-8777
Practice Address - Fax:217-698-8787
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL ILLINOIS ORAL AND MAXIOFACIAL SURGERY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-09
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty