=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285991935
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIO REYES ROSALES D.D.S., M.S.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2012
-----------------------------------------------------
Last Update Date | 04/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 PARK PL SUITE A
-----------------------------------------------------
City | SWANSEA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62226-2925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-233-7300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 933 ESIC DR
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62025-3813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-724-4852
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019027808
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 021002297
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------