NPIMap

Organization Active NPI

Southern Illinois University Carbondale Dental Sealant Program

  • Public Health Dentistry
  • Carbondale, IL
National Provider Identifier
1053582189
Registry record updated Jun 3, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Public Health DentistryTaxonomy code 1223D0001X
Legal business name
SOUTHERN ILLINOIS UNIVERSITY CARBONDALE DENTAL SEALANT PROGRAM
Practice address
1365 Douglas Dr RM 18
Casa, Sah, MC 6615
Carbondale, IL 62901-2583
Phone
(618) 453-7211
Fax
(618) 453-7020
NPI assigned
Mar 17, 2008
Organization subpart
Yes
Parent organization
SOUTHERN ILLINOIS UNIVERSITY CARBONDALEAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 3, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jennifer R Kreid, RDH, PHDH, BSDH
Title
DSGP Program Coordinator
Phone
(618) 453-8823

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Public Health DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223D0001X Primary
Dental Clinic/Center 261QD0000X

Addresses

Primary practice location

1365 Douglas Dr RM 18
Casa, Sah, MC 6615
Carbondale, IL 62901-2583

Mailing address

1365 Douglas Dr RM 18
Casa, Sah, MC 6615
Carbondale, IL 62901-2583
Phone (618) 453-7211

Other names 1

  • Childrens Healthcare Found Grant Other name

National Provider Directory

National Provider Directory
Tax ID family
DRS Herald and Thompson29 organizations share this tax ID, including this one
Part of
DRS Herald and Thompson

Other organizations with this tax ID 28

Organizations that report the same tax identification number in the National Provider Directory.

View all 28

Locations

1365 Douglas Dr
Rm 18
Carbondale, IL 62901
Phone (618) 453-7211

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1205712000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1748908800000",
    "number": "1053582189",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1365 DOUGLAS DR RM 18",
            "address_2": "CASA, SAH, MC 6615",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "629012583",
            "telephone_number": "618-453-7211",
            "fax_number": "618-453-7020"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1365 DOUGLAS DR RM 18",
            "address_2": "CASA, SAH, MC 6615",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "629012583",
            "telephone_number": "618-453-7211",
            "fax_number": "618-453-7020"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN ILLINOIS UNIVERSITY CARBONDALE DENTAL SEALANT PROGRAM",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTHERN ILLINOIS UNIVERSITY CARBONDALE",
        "enumeration_date": "2008-03-17",
        "last_updated": "2025-06-03",
        "certification_date": "2025-06-03",
        "status": "A",
        "authorized_official_last_name": "KREID",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "DSGP PROGRAM COORDINATOR",
        "authorized_official_telephone_number": "618-453-8823",
        "authorized_official_credential": "RDH, PHDH, BSDH"
    },
    "taxonomies": [
        {
            "code": "1223D0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Dental Public Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Childrens Healthcare Found Grant",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Carbondale, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 3, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.