Skip Navigation

Provider Information for 1710265434

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: 1710265434

Calendar   Last Updated:  2013-04-12
  Certification Date: 


Name Value
NPI 1710265434
Enumeration Date 2011-07-29
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 5811 N CYPRESS DR APT#3405
PEORIA, IL 61615-3376
United States

Phone: 203-215-4687 | Fax:
View Map External Link
Primary Practice Address 1403 W GLEN AVE
PEORIA, IL 61614-4705
United States

Phone: 309-692-4721 | Fax:
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 122300000X - Dentist IL 019028802