Healthcare Provider Details

I. General information

NPI: 1083905467
Provider Name (Legal Business Name): INTERNATIONAL DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 E STATE ST
ROCKFORD IL
61108-1914
US

IV. Provider business mailing address

3502 E STATE ST
ROCKFORD IL
61108-1914
US

V. Phone/Fax

Practice location:
  • Phone: 815-227-1050
  • Fax:
Mailing address:
  • Phone: 815-227-1050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: DR. RABEH R MOHAMMAD-SALAMAH
Title or Position: PRESIDENT
Credential: DDS
Phone: 773-227-1245