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General NPI Number Information
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NPI Number | 1528253994
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Entity Type | Organization
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Legal Business Name | PRAIRIE DENTAL ASSOCIATES, P.C.
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Dates
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Enumeration Date | 09/10/2007
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Last Update Date | 09/10/2007
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Provider Practice Location Address
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Address Line | 3220 GERIG DR
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City | BLOOMINGTON
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State | IL
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Zip | 61704-6394
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Country | US
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Telephone | 309-662-7722
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Fax |
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Provider Business Mailing Address
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Address Line | 3220 GERIG DR
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City | BLOOMINGTON
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State | IL
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Zip | 61704-6394
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Country | US
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Telephone | 309-662-7722
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. RICHARD A. STEPHEY
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Credential | DDS
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Telephone | 309-662-7722
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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 | IL
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