NPIMap

Organization Active NPI

Southern Illinois University Edwardsville School of Dental Medicine

  • General Practice Dentistry
  • Alton, IL
National Provider Identifier
1215912696
Registry record updated Jul 10, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
19018978 Issued in IL
Legal business name
SOUTHERN ILLINOIS UNIVERSITY EDWARDSVILLE SCHOOL OF DENTAL MEDICINE
Practice address
2800 College Ave
Alton, IL 62002-4700
Phone
(618) 474-7080
Fax
(618) 474-7029
NPI assigned
Dec 8, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 10, 2007

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

Authorized official

Name
Dr. Debra M Schwenk, DMDNPI 1083885149
Title
Associate Dean for Clinical Affairs
Phone
(618) 474-7080

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193200000X MULTI-SPECIALTY GROUP 1223G0001X 19018978 IL Primary

Addresses

Primary practice location

2800 College Ave
Alton, IL 62002-4700

Mailing address

2800 College Ave
Alton, IL 62002-4700
Phone (618) 474-7080

Other identifiers 1

IdentifierTypeStateIssuer
19018978MedicaidIL

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
14D2188836Southern Illinois University, School of Dental Med2800 College Ave, Alton, IL 62002ComplianceJun 2, 2028
14D2259493Southern Illinois University Dental Associates2800 College Ave, Alton, IL 62002ComplianceFeb 4, 2028

National Provider Directory

National Provider Directory
Tax ID family
Southern Illinois Univ6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

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

Locations

2800 College Ave
Alton, IL 62002
Phone (618) 474-7000

Practitioners & affiliated clinicians

Practitioners 19

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 19

NPI Registry JSON

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

{
    "created_epoch": "1134000000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1184025600000",
    "number": "1215912696",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2800 COLLEGE AVE",
            "city": "ALTON",
            "state": "IL",
            "postal_code": "620024700",
            "telephone_number": "618-474-7080",
            "fax_number": "618-474-7029"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2800 COLLEGE AVE",
            "city": "ALTON",
            "state": "IL",
            "postal_code": "620024700",
            "telephone_number": "618-474-7080",
            "fax_number": "618-474-7029"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN ILLINOIS UNIVERSITY EDWARDSVILLE SCHOOL OF DENTAL MEDICINE",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-12-08",
        "last_updated": "2007-07-10",
        "status": "A",
        "authorized_official_last_name": "SCHWENK",
        "authorized_official_first_name": "DEBRA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "ASSOCIATE DEAN FOR CLINICAL AFFAIRS",
        "authorized_official_telephone_number": "618-474-7080",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "IL",
            "license": "19018978",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "19018978",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Alton, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 10, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.