Organization
LEWIS AND CLARK COMMUNITY COLLEGE
Active
Other names
Lewis and Clark Community College Dental Hygiene Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOHN RANDALL MILLER D.D.S. (CLINIC SUPERVISOR)
(618) 468-4414
Entity
Organization
Contact information
Practice address
5800 GODFREY RD, GODFREY, IL 62035-2466
(618) 468-4463
(618) 468-4408
Mailing address
5800 GODFREY RD, GODFREY, IL 62035-2466
(618) 468-4463
(618) 468-4408
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
9176253
—
IL
Enumeration date
11/02/2005
Last updated
08/22/2020
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