Provider Demographics
NPI:1487810461
Name:VANCIL, S. MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:S. MICHAEL
Middle Name:
Last Name:VANCIL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 CEDAR CT
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5335
Mailing Address - Country:US
Mailing Address - Phone:618-529-3931
Mailing Address - Fax:618-529-1011
Practice Address - Street 1:1255 CEDAR CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5335
Practice Address - Country:US
Practice Address - Phone:618-529-3931
Practice Address - Fax:618-529-1011
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0172931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1770632119OtherCORPORATE NPI