1386525889 NPI number — 205 DIRECT DENTAL SERVICES INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386525889 NPI number — 205 DIRECT DENTAL SERVICES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
205 DIRECT DENTAL SERVICES INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386525889
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3957 N MULFORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61114-8004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-637-6400
Provider Business Mailing Address Fax Number:
815-637-6477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4151 SAMUELSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61109-3272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-637-6400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/10/2025

Additional Information

Authorized Official

Authorized Official Last Name:
OATES
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
CYRUS
Authorized Official Title or Position:
DENTIST / PRESIDENT
Authorized Official Telephone Number:
815-637-6400

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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