=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205058666
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AFFORDABLE DENTISTRY TODAY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 11/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1507 NORTH VETERANS PARKWAY SUITE 2
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-664-5033
-----------------------------------------------------
Fax | 309-663-0967
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1507 NORTH VETERANS PARKWAY SUITE 2
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-664-5033
-----------------------------------------------------
Fax | 309-663-0967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | TABATHA LEMKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-540-6078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------