Provider Demographics
NPI:1538607593
Name:NEAL FAMILY DENTISTRY
Entity type:Organization
Organization Name:NEAL FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WES
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-242-5054
Mailing Address - Street 1:3 DOCTORS PARK RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6200
Mailing Address - Country:US
Mailing Address - Phone:618-242-5054
Mailing Address - Fax:618-242-9311
Practice Address - Street 1:3 DOCTORS PARK RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6200
Practice Address - Country:US
Practice Address - Phone:618-242-5054
Practice Address - Fax:618-242-9311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.016293122300000X
IL019.030185122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty