Healthcare Provider Details

I. General information

NPI: 1033735089
Provider Name (Legal Business Name): TREVOR DANIEL RICHMOND DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11825 N KNOXVILLE AVE
DUNLAP IL
61525-8842
US

IV. Provider business mailing address

7713 S STRANZ RD
MAPLETON IL
61547-9412
US

V. Phone/Fax

Practice location:
  • Phone: 309-740-3901
  • Fax:
Mailing address:
  • Phone: 309-431-1512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021.003328
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.032728
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: