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General NPI Number Information
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NPI Number | 1225493034
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Entity Type | Organization
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Legal Business Name | ANDRIS FAMILY DENTAL, LLC
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Dates
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Enumeration Date | 12/21/2015
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Last Update Date | 12/21/2015
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Provider Practice Location Address
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Address Line | 636 W JEFFERSON ST
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City | MORTON
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State | IL
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Zip | 61550-1581
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Country | US
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Telephone | 309-263-8317
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Fax | 309-263-2175
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Provider Business Mailing Address
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Address Line | 636 W JEFFERSON ST
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City | MORTON
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State | IL
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Zip | 61550-1581
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Country | US
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Telephone | 309-263-8317
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Fax | 309-263-2175
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. RYAN WAYNE ANDRIS
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Credential | D.M.D.
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Telephone | 309-263-8317
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 019.029393
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License Number State | IL
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