| Organization Name: | SOUTHERN ILLINOIS UNIVERSITY CARBONDALE DENTAL SEALANT PROGRAM |
| NPI Number: | 1053582189 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | FAITH MILLER (DENTAL SEALANT PROGRAM CO-COORDINAT) |
| Mailing Address: | 1365 Douglas Dr Rm 18 Casa, Sah, Mc 6615 Carbondale |
| State: | IL US |
| Postal Code: | 629012583 |
| Phone Number: | 6184537211 |
| Fax Number: | 6184537020 |
| NPI Enumeration Date: | 03/17/2008 |
| NPI Last Update Date: | 03/17/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |