Basic Information
| Provider Information | |||||||||
| NPI: | 1700035730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PREVILLE | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | LYNETTE | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6000 BOND AVE | ||||||||
| Address2: | DENTAL CLINIC | ||||||||
| City: | CENTREVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622072328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183322740 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6000 BOND AVE | ||||||||
| Address2: | DENTAL CLINIC | ||||||||
| City: | CENTREVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622072328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183322740 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 04/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DD3187 | NM | N | Dental Providers | Dentist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 122300000X | 019029730 | IL | Y | Dental Providers | Dentist |
No ID Information.