1770755852 NPI number — DENTAL SEALANTS & MORE

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 1770755852 NPI number — DENTAL SEALANTS & MORE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL SEALANTS & MORE
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:
1770755852
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2126 N. UNIVERSITY ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-339-4433
Provider Business Mailing Address Fax Number:
309-406-1326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2126 N. UNIVERSITY ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-339-4433
Provider Business Practice Location Address Fax Number:
309-406-1326
Provider Enumeration Date:
03/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DIETZ
Authorized Official First Name:
RENEE
Authorized Official Middle Name:
KATHERINE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
309-339-4433

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  019-010639 , 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)

  • Identifier: 1001319 . This is a "DORAL DENTAL OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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