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General NPI Number Information
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NPI Number | 1679806194
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Entity Type | Organization
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Legal Business Name | RENEW ORTHODONTICS
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Dates
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Enumeration Date | 09/16/2009
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Last Update Date | 09/16/2009
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Provider Practice Location Address
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Address Line | 2335 SYCAMORE RD
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City | DEKALB
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State | IL
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Zip | 60115-2007
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Country | US
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Telephone | 815-756-5200
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Fax | 815-756-5567
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Provider Business Mailing Address
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Address Line | 2335 SYCAMORE RD
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City | DEKALB
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State | IL
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Zip | 60115-2007
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Country | US
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Telephone | 815-756-5200
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Fax | 815-756-5567
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. DARYL ASHBECK
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Credential | DDS MS
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Telephone | 815-756-5200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 019024635
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License Number State | IL
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