MEDICARE: RENKEN DENTISTRY PC

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	019025823	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710162326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENKEN DENTISTRY PC

Provider Business Mailing Address
First Line	:	2801 MANSION RD
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711-6724
Country	:	US
Telephone Number	:	217-483-7177
Fax Number	:	217-483-7190

Provider Business Practice Location Address
First Line	:	2801 MANSION RD
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711-6724
Country	:	US
Telephone Number	:	217-483-7177
Fax Number	:	217-483-7190

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOSHUA M RENKEN
Credential	:	D.D.S.
Telephone Number	:	217-483-7177

Provider Enumeration Date	:	01/02/2008
Last Update Date	:	08/28/2019

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Directions to “RENKEN DENTISTRY PC ” Practice Location

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