Provider Demographics
NPI:1184737363
Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Entity type:Organization
Organization Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PC PRESENDT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WORKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:1111 E WALNUT STE A1
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901
Mailing Address - Country:US
Mailing Address - Phone:618-529-2471
Mailing Address - Fax:618-529-2482
Practice Address - Street 1:1111 EAST WALNUT STREET
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-529-2471
Practice Address - Fax:618-529-2482
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-15
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0157651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty