Healthcare Provider Details

I. General information

NPI: 1013984541
Provider Name (Legal Business Name): CRAIG JAMES THATCHER
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/03/2006
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: 309-797-1720
  • Fax: 309-797-1720
Mailing address:
  • Phone: 309-797-1770
  • Fax: 309-797-1791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number19024622
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: