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General NPI Number Information
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NPI Number | 1568594638
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Entity Type | Individual
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Provider Name | SHERDON WADE CORDOVA DDS
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Gender | Male
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Dates
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Enumeration Date | 03/12/2007
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Last Update Date | 05/04/2011
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Provider Practice Location Address
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Address Line | 614 LAUREL DR
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City | SAINT JOSEPH
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State | IL
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Zip | 61873-9402
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Country | US
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Telephone | 217-383-3289
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Fax | 217-383-7071
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Provider Business Mailing Address
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Address Line | 614 LAUREL DR
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City | SAINT JOSEPH
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State | IL
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Zip | 61873-9402
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Country | US
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Telephone | 217-383-3289
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Fax | 217-383-7071
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 019.026964
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License Number State | IL
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