=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225469596
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK CITY DENTAL, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2013
-----------------------------------------------------
Last Update Date | 12/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 N COURT ST SUITE 100
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61103-6862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-708-6556
-----------------------------------------------------
Fax | 815-708-6477
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 N COURT ST SUITE 100
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61103-6862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-708-6556
-----------------------------------------------------
Fax | 815-708-6477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JASON M GRINTER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 815-708-6556
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019026609
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------