14D2237068 CLIA NUMBER - DYNAMIC DENTAL GROUP, P C

Laboratory Demographics

CLIA Number: 14D2237068

Facility Name: DYNAMIC DENTAL GROUP, P C

Facility Address:
2102 W RANDOLPH ST
VANDALIA, IL
ZIP 62471
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Facility Phone Number: 618 283-4900

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1811062557

Taxonomy: 1223G0001X - Dentist
A general dentist is the primary dental care provider for patients of all ages. The general dentist is responsible for the diagnosis, treatment, management and overall coordination of services related to patients' oral health needs.

CLIA Record

Field Name	Field Value
CLIA Number	14D2237068
LAB Type	Practitioner Other
Facility Name	DYNAMIC DENTAL GROUP, P C
Street	2102 W RANDOLPH ST
City	VANDALIA
State	IL
ZIP	62471
Phone	618 283-4900
CertificateType	4
CertificateEffectiveDate	9/22/2023
CertificateExpirationDate	9/21/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024