Smalltown Dental Glen LLC

NPI #1477148179 in Peoria, Illinois

Provider Information

NPI Number: 1477148179
Entity Type: Organization
Organization Name: Smalltown Dental Glen LLC
Subpart: Yes (part of a larger organization)
Parent Organization: SMALLTOWN DENTAL MANAGEMENT LLC
Primary Specialty: Dentist - General Practice
Enumeration Date: Mar 4, 2021
Last Updated: Mar 4, 2021

Practice Location

Address: 2015 W GLEN AVE STE 230
City: Peoria
State: Illinois
ZIP Code: 61614-4691
Phone: (309) 673-4616

Authorized Official

Name: LUKE OVERCASH
Title: OPERATIONS MANAGER
Phone: (309) 370-5853

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Dentist - General Practice — General Practice	1223G0001X	Primary

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