Healthcare Provider Details

I. General information

NPI: 1083875959
Provider Name (Legal Business Name): TSVETA VATCHEVA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4040 MORSAY DR
ROCKFORD IL
61107-4851
US

IV. Provider business mailing address

4040 MORSAY DR
ROCKFORD IL
61107-4851
US

V. Phone/Fax

Practice location:
  • Phone: 815-399-0866
  • Fax: 815-399-0895
Mailing address:
  • Phone: 815-399-0866
  • Fax: 815-399-0895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019027699
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: