Healthcare Provider Details

I. General information

NPI: 1649955923
Provider Name (Legal Business Name): VIRDEN FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N SPRINGFIELD ST
VIRDEN IL
62690-1455
US

IV. Provider business mailing address

155 N SPRINGFIELD ST
VIRDEN IL
62690-1455
US

V. Phone/Fax

Practice location:
  • Phone: 217-965-5631
  • Fax:
Mailing address:
  • Phone: 217-965-5631
  • 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: DR. ASHLEY NOWDOMSKI
Title or Position: GENERAL DENTIST
Credential: DMD
Phone: 708-897-7259