Healthcare Provider Details

I. General information

NPI: 1376014746
Provider Name (Legal Business Name): EAST MOLINE DENTAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2018
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 GREEN PARK AVE
COLONA IL
61241-9617
US

IV. Provider business mailing address

748 GREEN PARK AVE
COLONA IL
61241-9617
US

V. Phone/Fax

Practice location:
  • Phone: 309-792-2211
  • Fax: 309-792-4678
Mailing address:
  • Phone: 309-792-2211
  • Fax: 309-792-4678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL A KENDALL
Title or Position: DENTIST
Credential:
Phone: 309-755-1700