Healthcare Provider Details

I. General information

NPI: 1235250200
Provider Name (Legal Business Name): RIVER VALLEY ORAL AND MAXILLOFACIAL SURGERY CLINIC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 16TH AVE
MOLINE IL
61265
US

IV. Provider business mailing address

930 16TH AVE
MOLINE IL
61265
US

V. Phone/Fax

Practice location:
  • Phone: 309-797-1770
  • Fax: 309-797-1791
Mailing address:
  • Phone: 309-797-1770
  • Fax: 309-797-1791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. BRADLEY J LUTCHKA
Title or Position: ORAL SURGEON
Credential: DMD MD
Phone: 309-797-1770