Healthcare Provider Details

I. General information

NPI: 1114608965
Provider Name (Legal Business Name): DR MOSQUERA PROSTHODONTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 07/25/2023
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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JORGE ENRIQUE MOSQUERA CASTRILLON
Title or Position: DENTIST
Credential: DDS
Phone: 561-635-8018