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General NPI Number Information
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NPI Number | 1336477769
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Entity Type | Organization
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Legal Business Name | ROCKRIVER DENTAL LLC
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Dates
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Enumeration Date | 11/23/2009
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Last Update Date | 11/23/2009
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Provider Practice Location Address
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Address Line | 318 COLLEGE AVE
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City | ROCKFORD
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State | IL
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Zip | 61104-2922
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Country | US
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Telephone | 815-965-5555
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Fax | 815-965-5561
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Provider Business Mailing Address
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Address Line | 318 COLLEGE AVE
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City | ROCKFORD
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State | IL
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Zip | 61104-2922
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Country | US
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Telephone | 815-965-5555
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Fax | 815-965-5561
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. DUANE HANSEN
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Credential | D.D.S.
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Telephone | 815-965-5555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019019603
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License Number State | IL
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