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General NPI Number Information
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NPI Number | 1912036385
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Entity Type | Organization
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Legal Business Name | PRAIRIE CIRCLE DENTAL, P.C.
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Dates
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Enumeration Date | 03/03/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 703 N NILES AVE
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City | TUSCOLA
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State | IL
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Zip | 61953-1059
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Country | US
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Telephone | 217-253-5216
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Fax | 217-253-4949
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Provider Business Mailing Address
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Address Line | 703 N NILES AVE
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City | TUSCOLA
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State | IL
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Zip | 61953-1059
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Country | US
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Telephone | 217-253-5216
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Fax | 217-253-4949
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Authorized Official
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Title or Position | OWNER
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Name | DR. RICHARD D. DAVIDSON
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Credential | DMD
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Telephone | 217-253-5216
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | IL
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