Healthcare Provider Details

I. General information

NPI: 1073005708
Provider Name (Legal Business Name): ANDREW HADDOCK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 W JEFFERSON ST
MORTON IL
61550
US

IV. Provider business mailing address

636 W JEFFERSON ST
MORTON IL
61550
US

V. Phone/Fax

Practice location:
  • Phone: 309-263-8317
  • Fax:
Mailing address:
  • Phone: 309-263-8317
  • Fax: 920-787-4737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019034015
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1001807-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: