Healthcare Provider Details

I. General information

NPI: 1588204309
Provider Name (Legal Business Name): LADNER AND JAIN ORTHODONTICS, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1171 N HENDERSON ST
GALESBURG IL
61401-2523
US

IV. Provider business mailing address

1171 N HENDERSON ST
GALESBURG IL
61401-2523
US

V. Phone/Fax

Practice location:
  • Phone: 309-343-8727
  • Fax: 309-342-0491
Mailing address:
  • Phone: 309-343-8727
  • Fax: 309-342-0491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANGIE GUNTHER
Title or Position: TREATMENT COORDINATOR
Credential:
Phone: 309-343-8727