Healthcare Provider Details

I. General information

NPI: 1457801755
Provider Name (Legal Business Name): FOREST CITY DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 DAIMLER RD
ROCKFORD IL
61112-1063
US

IV. Provider business mailing address

1855 DAIMLER RD
ROCKFORD IL
61112-1063
US

V. Phone/Fax

Practice location:
  • Phone: 815-397-7454
  • Fax: 815-397-7555
Mailing address:
  • Phone: 815-397-7454
  • Fax: 815-397-7555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019026159
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES RANDOL STOVALL
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 815-397-7454