=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265946081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OMFS PRACTICE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2017
-----------------------------------------------------
Last Update Date | 12/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2917 CROSSING CT STE A
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61822-6185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-366-1246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2917 CROSSING CT STE A
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61822-6185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-366-1246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. VICTOR H ESCOBAR
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 217-366-1246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 021.002026
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------