Healthcare Provider Details

I. General information

NPI: 1649308230
Provider Name (Legal Business Name): TAZEWELL COUNTY HEALTH DEPARTMENT -DENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 RADIO CITY DRIVE SUITE A & B
NORTH PEKIN IL
61554
US

IV. Provider business mailing address

135 RADIO CITY DRIVE SUITE A & B
NORTH PEKIN IL
61554
US

V. Phone/Fax

Practice location:
  • Phone: 309-382-2229
  • Fax: 309-382-1155
Mailing address:
  • Phone: 309-382-2229
  • Fax: 309-382-1155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberE9993-0978-05
License Number StateIL

VIII. Authorized Official

Name: DR. JERRY LEE MARSHALL
Title or Position: DIRECTOR OF DENTAL SERVICES
Credential: DMD
Phone: 309-382-2229