1295192144 NPI number — WOOLERY DENTAL P.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 1295192144 NPI number — WOOLERY DENTAL P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOOLERY DENTAL P.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:
1295192144
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5301 E STATE ST STE 306
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:
61108-2390
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-399-2542
Provider Business Mailing Address Fax Number:
815-399-4716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5301 E STATE ST STE 306
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:
61108-2390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-399-2542
Provider Business Practice Location Address Fax Number:
815-399-4716
Provider Enumeration Date:
01/23/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WOOLERY
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
K
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
815-399-2542

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  019026188 , 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)