Healthcare Provider Details

I. General information

NPI: 1982734919
Provider Name (Legal Business Name): MARY ANN RACKAUSKAS D.M.D.M.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 RICKARD RD
SPRINGFIELD IL
62704-1017
US

IV. Provider business mailing address

1112 RICKARD RD
SPRINGFIELD IL
62704-1017
US

V. Phone/Fax

Practice location:
  • Phone: 217-546-5437
  • Fax: 217-546-5497
Mailing address:
  • Phone: 217-546-5437
  • Fax: 217-546-5497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: