Provider Demographics
NPI:1205001914
Name:MOBI-DENT P.C.
Entity Type:Organization
Organization Name:MOBI-DENT P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AVERY
Authorized Official - Middle Name:CORTEZ
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-228-0474
Mailing Address - Street 1:15652 94TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-2175
Mailing Address - Country:US
Mailing Address - Phone:314-837-6599
Mailing Address - Fax:314-837-8918
Practice Address - Street 1:1719 HEATHER HILL CRES
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2041
Practice Address - Country:US
Practice Address - Phone:708-228-0474
Practice Address - Fax:314-837-8918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022452320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities