Healthcare Provider Details

I. General information

NPI: 1811379142
Provider Name (Legal Business Name): ROCK RIVER ORAL SURGERY & DENTAL IMPLANT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

973 FEATHERSTONE RD SUITE 102
ROCKFORD IL
61107-5912
US

IV. Provider business mailing address

973 FEATHERSTONE RD SUITE 102
ROCKFORD IL
61107-5912
US

V. Phone/Fax

Practice location:
  • Phone: 815-399-1234
  • Fax: 815-399-2423
Mailing address:
  • Phone: 815-399-1234
  • Fax: 815-399-2423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number019030148
License Number StateWI

VIII. Authorized Official

Name: SHEA MCCUE
Title or Position: ORAL SURGEON/OWNER
Credential: DDS
Phone: 815-399-1234