Healthcare Provider Details

I. General information

NPI: 1871190884
Provider Name (Legal Business Name): JORGE ENRIQUE MOSQUERA CASTRILLON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 07/26/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

687 E LINTON AVE
SPRINGFIELD IL
62703-5902
US

IV. Provider business mailing address

3500 SANDPIPER DR
SPRINGFIELD IL
62711-6722
US

V. Phone/Fax

Practice location:
  • Phone: 718-909-2550
  • Fax:
Mailing address:
  • Phone: 561-635-8018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019032932
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number021003081
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: