Healthcare Provider Details

I. General information

NPI: 1265946081
Provider Name (Legal Business Name): OMFS PRACTICE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2917 CROSSING CT STE A
CHAMPAIGN IL
61822-6185
US

IV. Provider business mailing address

2917 CROSSING CT STE A
CHAMPAIGN IL
61822-6185
US

V. Phone/Fax

Practice location:
  • Phone: 217-366-1246
  • Fax:
Mailing address:
  • Phone: 217-366-1246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021.002026
License Number StateIL

VIII. Authorized Official

Name: DR. VICTOR H ESCOBAR
Title or Position: PRESIDENT
Credential: DDS
Phone: 217-366-1246