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General NPI Number Information
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NPI Number | 1922457126
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Entity Type | Organization
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Legal Business Name | MAIN SQUARE DENTAL
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Dates
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Enumeration Date | 06/08/2016
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Last Update Date | 06/08/2016
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Provider Practice Location Address
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Address Line | 5392 WILLIAMS DR
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City | ROSCOE
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State | IL
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Zip | 61073-7320
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Country | US
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Telephone | 815-623-9292
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Fax |
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Provider Business Mailing Address
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Address Line | 5392 WILLIAMS DR
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City | ROSCOE
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State | IL
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Zip | 61073-7320
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Country | US
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Telephone | 815-623-9292
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Fax |
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Authorized Official
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Title or Position | DR
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Name | DR. MARTHA MULDOWNEY
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Credential |
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Telephone | 815-623-9292
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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 | 19016896
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License Number State | IL
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