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General NPI Number Information
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NPI Number | 1811379142
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Entity Type | Organization
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Legal Business Name | ROCK RIVER ORAL SURGERY & DENTAL IMPLANT CENTER LLC
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Dates
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Enumeration Date | 06/23/2015
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Last Update Date | 06/23/2015
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Provider Practice Location Address
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Address Line | 973 FEATHERSTONE RD SUITE 102
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City | ROCKFORD
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State | IL
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Zip | 61107-5912
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Country | US
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Telephone | 815-399-1234
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Fax | 815-399-2423
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Provider Business Mailing Address
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Address Line | 973 FEATHERSTONE RD SUITE 102
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City | ROCKFORD
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State | IL
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Zip | 61107-5912
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Country | US
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Telephone | 815-399-1234
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Fax | 815-399-2423
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Authorized Official
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Title or Position | ORAL SURGEON/OWNER
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Name | SHEA MCCUE
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Credential | DDS
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Telephone | 815-399-1234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number | 019030148
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License Number State | WI
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