Healthcare Provider Details

I. General information

NPI: 1942204201
Provider Name (Legal Business Name): MARK A. FAUGHT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 02/27/2015
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 04/10/2006

III. Provider practice location address

730 ENTERPRISE DRIVE
RANTOUL IL
61866-3689
US

IV. Provider business mailing address

730 ENTERPRISE DRIVE
RANTOUL IL
61866-3689
US

V. Phone/Fax

Practice location:
  • Phone: 217-359-9900
  • Fax: 217-892-8869
Mailing address:
  • Phone: 217-359-9900
  • Fax: 217-892-8868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019019181
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: