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General NPI Number Information
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NPI Number | 1871190884
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Entity Type | Individual
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Provider Name | JORGE ENRIQUE MOSQUERA CASTRILLON DDS
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Gender | Male
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Dates
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Enumeration Date | 10/02/2020
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Last Update Date | 07/26/2023
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Provider Practice Location Address
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Address Line | 687 E LINTON AVE
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City | SPRINGFIELD
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State | IL
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Zip | 62703-5902
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Country | US
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Telephone | 718-909-2550
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Fax |
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Provider Business Mailing Address
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Address Line | 3500 SANDPIPER DR
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City | SPRINGFIELD
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State | IL
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Zip | 62711-6722
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Country | US
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Telephone | 561-635-8018
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Fax |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 019032932
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 021003081
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License Number State | IL
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