Provider Demographics
NPI:1124280706
Name:3-D IMAGING OF SOUTHERN ILLINOIS, INC.
Entity type:Organization
Organization Name:3-D IMAGING OF SOUTHERN ILLINOIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:K
Authorized Official - Last Name:BURDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:618-222-1722
Mailing Address - Street 1:5899 N BELT W
Mailing Address - Street 2:SUITE B
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-4617
Mailing Address - Country:US
Mailing Address - Phone:618-222-1722
Mailing Address - Fax:
Practice Address - Street 1:5899 N BELT W
Practice Address - Street 2:SUITE B
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-4617
Practice Address - Country:US
Practice Address - Phone:618-222-1722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-13956261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental