# SOUTHERN ILLINOIS PEDIATRIC DENTISTRY OF EDWARDSVILLE

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1568925014
- **Authorized official:** DR. CHRISTINE ANNE WOHLFORD DMD (DENTIST/MEMBER)
- **Authorized official phone:** (618) 655-3272

## Contact information

- **Practice address:** 1419 LEWIS ROAD, SUITE 2, EDWARDSVILLE, IL 62025
- **Practice address phone:** (618) 655-3272
- **Practice address fax:** (618) 655-3273
- **Mailing address:** 1419 LEWIS ROAD, SUITE 2, EDWARDSVILLE, IL 62025
- **Mailing address phone:** (618) 655-3272
- **Mailing address fax:** (618) 655-3273

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223P0221X | Pediatric Dentistry | — | NULL | Yes |
| 1223P0221X | Pediatric Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 04/11/2019
- **Last updated:** 04/11/2019