Provider Demographics
NPI:1760211494
Name:CENTRAL ILLINOIS DENTAL SLEEP CENTER
Entity type:Organization
Organization Name:CENTRAL ILLINOIS DENTAL SLEEP CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-546-0351
Mailing Address - Street 1:2501 W ILES AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6482
Mailing Address - Country:US
Mailing Address - Phone:217-546-0351
Mailing Address - Fax:217-698-1638
Practice Address - Street 1:2501 W ILES AVE STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6482
Practice Address - Country:US
Practice Address - Phone:217-546-0351
Practice Address - Fax:217-698-1638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies