Provider Demographics
NPI:1538180617
Name:SOUTHERN ILLINOIS ORAL & MAXILLOFACIAL SURGERY, LTD.
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS ORAL & MAXILLOFACIAL SURGERY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:HESTERBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-233-8080
Mailing Address - Street 1:2900 FRANK SCOTT PKWY W
Mailing Address - Street 2:SUITE 960
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5000
Mailing Address - Country:US
Mailing Address - Phone:618-233-8080
Mailing Address - Fax:618-233-1192
Practice Address - Street 1:2900 FRANK SCOTT PKWY W
Practice Address - Street 2:SUITE 960
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-233-8080
Practice Address - Fax:618-233-1192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021-0013641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL798951Medicare ID - Type UnspecifiedGROUP ID
ILCB3940Medicare ID - Type UnspecifiedRAILROAD MEDICARE GRP ID
ILW25804Medicare UPIN