Healthcare Provider Details

I. General information

NPI: 1245673441
Provider Name (Legal Business Name): MICHAEL DAVID DEGOULD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 MCFARLAND RD SUITE C
ROCKFORD IL
61107-6819
US

IV. Provider business mailing address

2835 MCFARLAND RD SUITE C
ROCKFORD IL
61107-6819
US

V. Phone/Fax

Practice location:
  • Phone: 815-654-0039
  • Fax: 815-654-0650
Mailing address:
  • Phone: 815-654-0039
  • Fax: 815-654-0650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019019722
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: