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Dental Care Facilities

Dupo, Illinois

Provider NPI: 1063552453

Organization Information:
Authorized Official:  RONALD D GERSTEN  OWNER  618-2864400

Practice Location:
195 S MAIN ST  DUPO, IL 62239 US
Tel: 618-286-4400  Fax: --

Business Mailing Address:
195 S MAIN ST  DUPO, IL 62239 US
Tel: --  Fax: --

Entity Type: Organization


PrimaryCodeCategory/DescriptionStateLicense Number
Y261QD0000XAmbulatory Health Care Facilities

Other Provider Identifiers:

Code values:
01, Other | 02, Medicare Upin | 04, Medicare Id-Type Unspecified
05, Medicaid | 06, Medicare Oscar/Certification | 07, Medicare NSC | 08, Medicare Pin


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