Healthcare Provider Details

I. General information

NPI: 1609141464
Provider Name (Legal Business Name): KIDS FIRST DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7314 N WILLOW LAKE CT STE D
PEORIA IL
61614-8289
US

IV. Provider business mailing address

7314 N WILLOW LAKE CT STE D
PEORIA IL
61614-8289
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-0175
  • Fax: 309-692-3139
Mailing address:
  • Phone: 309-692-0175
  • Fax: 309-692-3139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. LAURA DONLAN
Title or Position: OWNER
Credential: DDS
Phone: 309-692-0175