1831606433 NPI number — GALVA FAMILY DENTISTRY, INC

Table of content: (NPI 1831606433)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831606433 NPI number — GALVA FAMILY DENTISTRY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GALVA FAMILY DENTISTRY, 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:
THE KNOLLS FAMILY DENTISTRY
Provider Other Organization Name Type Code:
3
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:
1831606433
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALVA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61434-1766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-932-2000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 W STRATFORD DR
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:
61614-7301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-682-6459
Provider Business Practice Location Address Fax Number:
309-682-7036
Provider Enumeration Date:
01/04/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BATES
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
309-932-2000

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  019016453 , 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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