MEDICARE: SARA RODEFFER D.M.D

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	1223G0001X	General Practice Dentistry	019.030790	IL

General Provider Information

NPI Number	:	1578915260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA RODEFFER D.M.D

Provider Business Mailing Address
First Line	:	3740 E LAKE CTR
Second Line	:	SUITE B
City	:	QUINCY
State	:	IL
Zip	:	62305-5805
Country	:	US
Telephone Number	:	217-214-4545
Fax Number	:	217-214-4546

Provider Business Practice Location Address
First Line	:	3740 E LAKE CTR
Second Line	:	SUITE B
City	:	QUINCY
State	:	IL
Zip	:	62305-5805
Country	:	US
Telephone Number	:	217-214-4545
Fax Number	:

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

Provider Enumeration Date	:	07/06/2016
Last Update Date	:	10/20/2016

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