Healthcare Provider Details

I. General information

NPI: 1750553327
Provider Name (Legal Business Name): DAVID R TROST DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 RADIO CITY DR STE F
NORTH PEKIN IL
61554-1570
US

IV. Provider business mailing address

137 RADIO CITY DR STE F
NORTH PEKIN IL
61554-1570
US

V. Phone/Fax

Practice location:
  • Phone: 309-382-6404
  • Fax: 309-382-6405
Mailing address:
  • Phone: 309-382-6404
  • Fax: 309-382-6405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019016607
License Number StateIL

VIII. Authorized Official

Name: DR. DAVID RALPH TROST
Title or Position: PRESIDENT
Credential: DDS
Phone: 309-382-6404