Healthcare Provider Details

I. General information

NPI: 1043480098
Provider Name (Legal Business Name): DUQUOIN DENTAL ASSOCIATES, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 S WASHINGTON ST
DU QUOIN IL
62832-3853
US

IV. Provider business mailing address

1226 S WASHINGTON ST PO BOX 330
DU QUOIN IL
62832-3853
US

V. Phone/Fax

Practice location:
  • Phone: 618-542-8832
  • Fax: 618-542-9255
Mailing address:
  • Phone: 618-542-8832
  • Fax: 618-542-9255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. ISAAC E DAVISON
Title or Position: PRESIDENT/OWNER
Credential: D.D.S.
Phone: 618-542-5889