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General NPI Number Information
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NPI Number | 1154357291
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Entity Type | Organization
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Legal Business Name | ASSOCIATED ORAL AND MAXILLOFACIAL SURGEONS OF PEORIA, LTD
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Dates
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Enumeration Date | 06/23/2006
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Last Update Date | 11/05/2024
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Provider Practice Location Address
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Address Line | 5720 N KNOXVILLE AVE
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City | PEORIA
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State | IL
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Zip | 61614-4331
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Country | US
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Telephone | 309-682-1213
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Fax | 309-682-5386
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Provider Business Mailing Address
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Address Line | 5720 N KNOXVILLE AVE
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City | PEORIA
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State | IL
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Zip | 61614-4331
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Country | US
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Telephone | 309-682-1213
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Fax | 309-682-5386
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Authorized Official
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Title or Position | PRACTICE LEADER
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Name | ROBYN WOLFE
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Credential |
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Telephone | 309-682-1249
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 019023700
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 019024407
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License Number State | IL
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