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General NPI Number Information
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NPI Number | 1730547936
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Entity Type | Organization
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Legal Business Name | PERRYVILLE DENTIST PC
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Dates
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Enumeration Date | 02/02/2016
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Last Update Date | 02/02/2016
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Provider Practice Location Address
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Address Line | 845 S PERRYVILLE RD UNIT 119
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City | ROCKFORD
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State | IL
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Zip | 61108
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Country | US
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Telephone | 847-354-0127
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Fax |
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Provider Business Mailing Address
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Address Line | 845 S PERRYVILLE RD UNIT 119
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City | ROCKFORD
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State | IL
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Zip | 61108
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Country | US
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Telephone | 847-354-0127
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JABAL R PATEL
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Credential | DMD
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Telephone | 847-354-0127
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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 | 019.026938
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License Number State | IL
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