1649592353 NPI number — TWO RIVERS PEDIATRIC DENTISTRY, L.L.C.

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 1649592353 NPI number — TWO RIVERS PEDIATRIC DENTISTRY, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TWO RIVERS PEDIATRIC DENTISTRY, L.L.C.
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:
1649592353
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1872 AVENUE OF THE CITIES
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOLINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61265-4878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-797-3020
Provider Business Mailing Address Fax Number:
309-797-3212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1872 AVENUE OF THE CITIES
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOLINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-797-3020
Provider Business Practice Location Address Fax Number:
309-797-3212
Provider Enumeration Date:
02/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDS
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
309-797-3020

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  019025264 , 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)





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