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Provider Information for 1083793939

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1083793939

Calendar   Last Updated:  2021-03-22
  Certification Date:  2021-03-22


Name Value
NPI 1083793939
Enumeration Date 2006-11-03
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 3 QUAIL XING
ROCHESTER, IL 62563-9520
United States

Phone: 217-498-7006 | Fax:
View Map External Link
Primary Practice Address 3240 HEDLEY RD SUITE B
SPRINGFIELD, IL 62711-6360
United States

Phone: 217-698-3400 | Fax: 217-698-3410
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223G0001X - Dentist General Practice IL 019.024738