Healthcare Provider Details

I. General information

NPI: 1619946878
Provider Name (Legal Business Name): ASSOCIATED DENTISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 N PLUM ST
PONTIAC IL
61764-1818
US

IV. Provider business mailing address

519 N PLUM ST
PONTIAC IL
61764-1818
US

V. Phone/Fax

Practice location:
  • Phone: 815-844-6184
  • Fax: 815-844-1071
Mailing address:
  • Phone: 815-844-6184
  • Fax: 815-844-1071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number06000956
License Number StateIL

VIII. Authorized Official

Name: MR. JAMES A DAY
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 815-844-6184