MEDICARE: DR. THOMAS ALLEN DANIELS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry		IL

General Provider Information

NPI Number	:	1295951317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS ALLEN DANIELS D.D.S.

Provider Business Mailing Address
First Line	:	6050 BRYNWOOD DR
Second Line	:	SUITE 201
City	:	ROCKFORD
State	:	IL
Zip	:	61114-6579
Country	:	US
Telephone Number	:	815-877-7079
Fax Number	:

Provider Business Practice Location Address
First Line	:	6050 BRYNWOOD DR
Second Line	:	SUITE 201
City	:	ROCKFORD
State	:	IL
Zip	:	61114-6579
Country	:	US
Telephone Number	:	815-877-7079
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	07/08/2007

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