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General NPI Number Information
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NPI Number | 1760667307
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Entity Type | Organization
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Legal Business Name | BUFFALO PRAIRIE DENTAL CARE OF PITTSFIELD, INC
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Dates
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Enumeration Date | 01/02/2008
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Last Update Date | 01/02/2008
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Provider Practice Location Address
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Address Line | 850 N JACKSON ST
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City | PITTSFIELD
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State | IL
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Zip | 62363-1206
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Country | US
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Telephone | 217-285-4084
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Fax |
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Provider Business Mailing Address
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Address Line | 850 N JACKSON ST
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City | PITTSFIELD
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State | IL
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Zip | 62363-1206
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Country | US
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Telephone | 217-285-4084
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROY GLENN NORTHCUTT
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Credential | DMD
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Telephone | 217-285-4084
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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 | 0190242471
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License Number State | IL
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Taxonomy #2
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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 | IL
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