Healthcare Provider Details

I. General information

NPI: 1467455378
Provider Name (Legal Business Name): JOSHUA MATTHEW RENKEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 PIPER GLEN DR STE B
SPRINGFIELD IL
62711-7390
US

IV. Provider business mailing address

901 MONARCH DR
CHATHAM IL
62629-9672
US

V. Phone/Fax

Practice location:
  • Phone: 217-483-7177
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: