=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346318532
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL DEGOULD DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 01/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2835 MCFARLAND ROAD SUITE C
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-654-0039
-----------------------------------------------------
Fax | 815-654-0650
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2835 MCFARLAND ROAD SUITE C
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-654-0039
-----------------------------------------------------
Fax | 815-654-0650
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORAL SURGEON OWNER
-----------------------------------------------------
Name | DR. MICHAEL DAVID DEGOULD
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 815-654-0039
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 021001500
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------