Healthcare Provider Details

I. General information

NPI: 1215558390
Provider Name (Legal Business Name): VERHEECKE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S MAIN ST
ORANGEVILLE IL
61060-9244
US

IV. Provider business mailing address

PO BOX 456
ORANGEVILLE IL
61060-0456
US

V. Phone/Fax

Practice location:
  • Phone: 815-789-4611
  • Fax: 815-789-4612
Mailing address:
  • Phone: 815-789-4611
  • Fax: 815-789-4612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. PENNY K BOSE
Title or Position: OFFICE MANAGER
Credential:
Phone: 815-789-4611