1538350533 NPI number — RIVERSIDE DENTAL CENTER

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 1538350533 NPI number — RIVERSIDE DENTAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE DENTAL CENTER
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:
1538350533
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2028 E RIVERSIDE BLVD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
LOVES PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61111-4804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-877-4300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2028 E RIVERSIDE BLVD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
LOVES PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61111-4804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-877-4300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DONNELLI
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
815-877-4300

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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