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General NPI Number Information
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NPI Number | 1932683315
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Entity Type | Organization
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Legal Business Name | JUSTIN T. DURANCIK, DDS, PLLC
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Dates
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Enumeration Date | 09/20/2018
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Last Update Date | 09/20/2018
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Provider Practice Location Address
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Address Line | 619 E MAIN ST
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City | GENOA
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State | IL
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Zip | 60135-1309
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Country | US
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Telephone | 815-784-5166
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Fax |
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Provider Business Mailing Address
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Address Line | 16488 E MCNEAL RD
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City | MONROE CENTER
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State | IL
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Zip | 61052-9719
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Country | US
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Telephone | 815-761-7159
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | JUSTIN TYLER DURANCIK
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Credential | DDS
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Telephone | 815-761-7159
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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