| Southern Illinois University Edwardsville School Of Dental Medicine | |
|
411 E Broadway E St Louis IL 62201-2904 | |
| (618) 682-8318 | |
| (618) 474-7029 |
| Full Name | Southern Illinois University Edwardsville School Of Dental Medicine |
|---|---|
| Speciality | Dentist |
| Location | 411 E Broadway, E St Louis, Illinois |
| Authorized Official Name and Position | Dennis E Savoca (ASSOCIATE DEAN FOR CLINICAL AFFAIRS) |
| Authorized Official Contact | 6184747090 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Southern Illinois University Edwardsville School Of Dental Medicine 2800 College Ave Alton IL 62002-4700 Ph: (618) 474-7090 | Southern Illinois University Edwardsville School Of Dental Medicine 411 E Broadway E St Louis IL 62201-2904 Ph: (618) 682-8318 |
| NPI Number | 1760467146 |
|---|---|
| Provider Enumeration Date | 12/08/2005 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1760467146 | NPI | - | NPPES |
| 19018978 | Medicaid | IL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | 19018978 (Illinois) | Primary |