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General NPI Number Information
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NPI Number | 1346563525
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Entity Type | Organization
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Legal Business Name | MODERN DENTAL OF ROCKFORD LLC
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Dates
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Enumeration Date | 03/02/2010
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Last Update Date | 03/02/2010
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Provider Practice Location Address
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Address Line | 1321 SANDY HOLLOW RD
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City | ROCKFORD
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State | IL
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Zip | 61109-2120
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Country | US
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Telephone | 815-209-9070
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Fax |
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Provider Business Mailing Address
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Address Line | 1321 SANDY HOLLOW RD
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City | ROCKFORD
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State | IL
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Zip | 61109-2120
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Country | US
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Telephone | 815-209-9070
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JEFF THOMAS
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Credential |
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Telephone | 618-532-4902
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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 |
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License Number State |
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