Healthcare Provider Details

I. General information

NPI: 1285712653
Provider Name (Legal Business Name): BERNARDI & GROESCH DDS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2534 FARRAGUT DRIVE
SPRINGFIELD IL
62704
US

IV. Provider business mailing address

2534 FARRAGUT DRIVE
SPRINGFIELD IL
62704
US

V. Phone/Fax

Practice location:
  • Phone: 217-546-4674
  • Fax: 217-546-4659
Mailing address:
  • Phone: 217-546-4674
  • Fax: 217-546-4659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. CHARLES WILLIAM GROESCH
Title or Position: PRESIDENT
Credential: DDS
Phone: 217-546-4674