Provider Demographics
NPI:1043589526
Name:JILL KINSELLA DMD LLC
Entity type:Organization
Organization Name:JILL KINSELLA DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KINSELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-744-1969
Mailing Address - Street 1:703 SEIBERT RD.
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225
Mailing Address - Country:US
Mailing Address - Phone:618-744-1969
Mailing Address - Fax:618-744-1986
Practice Address - Street 1:703 SEIBERT RD.
Practice Address - Street 2:SUITE 5
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225
Practice Address - Country:US
Practice Address - Phone:618-744-1969
Practice Address - Fax:618-744-1986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027404122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty