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General NPI Number Information
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NPI Number | 1366710410
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Entity Type | Organization
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Legal Business Name | IIDSM BLOOMINGTON LLC
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Dates
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Enumeration Date | 12/05/2011
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Last Update Date | 05/16/2012
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Provider Practice Location Address
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Address Line | 2309 E EMPIRE ST 500
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City | BLOOMINGTON
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State | IL
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Zip | 61704-8636
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Country | US
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Telephone | 309-319-6568
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Fax |
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Provider Business Mailing Address
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Address Line | 11825 STATE ROUTE 40 SUITE 100
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City | DUNLAP
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State | IL
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Zip | 61525-8842
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Country | US
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Telephone | 309-243-1341
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Fax | 309-240-0351
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Authorized Official
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Title or Position | ACCOUNTS RECEIVABLE MANAGER
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Name | CAILIN SPENCER
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Credential |
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Telephone | 309-243-1341
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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 |
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License Number State |
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