Healthcare Provider Details

I. General information

NPI: 1487919866
Provider Name (Legal Business Name): BUSHNELL FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E WATER ST
BUSHNELL IL
61422-1764
US

IV. Provider business mailing address

525 E WATER ST
BUSHNELL IL
61422-1764
US

V. Phone/Fax

Practice location:
  • Phone: 309-772-2124
  • Fax:
Mailing address:
  • Phone: 309-772-2124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019-028904
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020-010827
License Number StateIL

VIII. Authorized Official

Name: DR. CYNTHIA PAIGE MCCORD
Title or Position: OWNER
Credential: DDS
Phone: 309-772-2124