Provider Demographics
NPI:1104254960
Name:SCHREDER FAMILY DENTAL
Entity type:Organization
Organization Name:SCHREDER FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:N
Authorized Official - Last Name:EGHIGIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-722-5300
Mailing Address - Street 1:4023 N ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1931
Mailing Address - Country:US
Mailing Address - Phone:618-722-5300
Mailing Address - Fax:
Practice Address - Street 1:4023 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1931
Practice Address - Country:US
Practice Address - Phone:618-722-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190251281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty