MEDICARE: JOSHUA MATTHEW RENKEN DDS

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	122300000X	Dentist		IL

General Provider Information

NPI Number	:	1467455378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSHUA MATTHEW RENKEN DDS

Provider Business Mailing Address
First Line	:	901 MONARCH DR
Second Line	:
City	:	CHATHAM
State	:	IL
Zip	:	62629-9672
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7000 PIPER GLEN DR
Second Line	:	STE B
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711-7390
Country	:	US
Telephone Number	:	217-483-7177
Fax Number	:

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	07/08/2007

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