Healthcare Provider Details

I. General information

NPI: 1912036385
Provider Name (Legal Business Name): PRAIRIE CIRCLE DENTAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 N NILES AVE
TUSCOLA IL
61953-1059
US

IV. Provider business mailing address

703 N NILES AVE
TUSCOLA IL
61953-1059
US

V. Phone/Fax

Practice location:
  • Phone: 217-253-5216
  • Fax: 217-253-4949
Mailing address:
  • Phone: 217-253-5216
  • Fax: 217-253-4949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. RICHARD D. DAVIDSON
Title or Position: OWNER
Credential: DMD
Phone: 217-253-5216