SOUTHERN ILLINOIS UNIVERSITY EDWARDSVILLE SCHOOL OF DENTAL MEDICINE
NPI 1215912696
Dentist - General Practice in Alton, IL

Q: What is Southern Illinois University Edwardsville School Of Dental Medicine's specialty?

The primary specialty registered for this NPI is Dentist, specializing in General Practice, with taxonomy code 1223G0001X.

Active since December 08, 2005CLIA 14D2188836 · Certificate of Compliance

2800 COLLEGE AVE, ALTON, IL 62002(618) 474-7080(618) 474-7029 Get Directions Write a Review

NPPES record last updated: July 10, 2007. Verified against the NPPES registry weekly; last sync: August 09, 2026.

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About Southern Illinois University Edwardsville School Of Dental Medicine NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

SOUTHERN ILLINOIS UNIVERSITY EDWARDSVILLE SCHOOL OF DENTAL MEDICINE (NPI 1215912696) is a healthcare organization registered as a general practice in Alton, Illinois and active in the NPI registry since December 2005. The organization holds a CLIA Certificate of Compliance certificate valid through June 2, 2028 and lists Debra M Schwenk, Associate Dean For Clinical Affairs, as its authorized official.

NPPES Registry Identity

NPI1215912696

Entity TypeOrganization

Primary Taxonomy1223G0001X

Legal Business NameSOUTHERN ILLINOIS UNIVERSITY EDWARDSVILLE SCHOOL OF DENTAL MEDICINE

Location Address2800 COLLEGE AVEAlton, IL 62002-4700

Mailing Address2800 College AveAlton, IL 62002-4700 · (618) 474-7080 · Fax (618) 474-7029

Phone(618) 474-7080

Fax(618) 474-7029

Organization SubpartNo

Authorized OfficialDebra M SchwenkAssociate Dean For Clinical Affairs · (618) 474-7080

Enumeration DateDecember 8, 2005

Last NPPES UpdateJuly 10, 2007

✔ NPI 1215912696 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyDentist · General PracticeDental Providers

Taxonomy Code1223G0001X

License✔ Licensed in IL · 19018978

Definition

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.

2800 COLLEGE AVE, Alton, IL 62002

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Other Identifiers 1

Medicaid19018978IL

Group Practice 1

Group TaxonomyThis provider is a business group of one or more individual practitioners, who practice with different areas of specialization.193200000X MULTI-SPECIALTY GROUP

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Compliance 14D2188836

Southern Illinois University, School Of Dental Med · Alton, IL

Active · expires Jun 2, 2028

CLIA Number14D2188836

Laboratory TypeSchool/Student Health Service

Certificate Effective DateJune 3, 2026

Certificate Expiration DateJune 2, 2028

Laboratory DirectorJasbir D. Upadhyaya

Laboratory Phone(618) 474-7100

Laboratory LocationSouthern Illinois University, School Of Dental Med2800 College Ave, Alton, IL 62002

CLIA data matches this NPI record on: Address

This certificate is issued to a laboratory after an inspection that finds the laboratory to be in compliance with all applicable CLIA requirements.

Other Providers at the Same Location NPPES 20

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

JESSICA CHELLIS

Dentist