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General NPI Number Information
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NPI Number | 1295988574
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Entity Type | Organization
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Legal Business Name | PERIODONTICS OF ROCKFORD LTD.
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Dates
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Enumeration Date | 10/30/2008
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Last Update Date | 10/30/2008
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Provider Practice Location Address
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Address Line | 1055 FEATHERSTONE RD
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City | ROCKFORD
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State | IL
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Zip | 61107
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Country | US
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Telephone | 815-227-5858
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Fax | 815-227-6238
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Provider Business Mailing Address
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Address Line | 1055 FEATHERSTONE RD
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City | ROCKFORD
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State | IL
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Zip | 61107
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Country | US
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Telephone | 815-227-5858
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Fax | 815-227-6238
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Authorized Official
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Title or Position | PERIODONTIST
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Name | JEFFREY V.A. BURCH
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Credential | D.M.D., M.S.
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Telephone | 815-227-5858
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 021002217
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License Number State | IL
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