Healthcare Provider Details

I. General information

NPI: 1336134097
Provider Name (Legal Business Name): TODD J COLE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 12/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 CASA PARK DR
MT ZION IL
62549-1757
US

IV. Provider business mailing address

2602 LAKE REUNION RD
DECATUR IL
62521-8407
US

V. Phone/Fax

Practice location:
  • Phone: 217-864-6016
  • Fax:
Mailing address:
  • Phone: 217-423-0607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019-023602
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: