Healthcare Provider Details

I. General information

NPI: 1710985759
Provider Name (Legal Business Name): CAPODICE, EFAW, OCHELTREE & ELGER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N REGENCY DR
BLOOMINGTON IL
61701-3515
US

IV. Provider business mailing address

109 N REGENCY DR
BLOOMINGTON IL
61701-3515
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-2526
  • Fax: 309-663-4788
Mailing address:
  • Phone: 309-663-2526
  • Fax: 309-663-4788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: MRS. KYNDRA BATA
Title or Position: OFFICE MANAGER
Credential:
Phone: 309-663-2526