Provider Demographics
NPI:1235250200
Name:RIVER VALLEY ORAL AND MAXILLOFACIAL SURGERY CLINIC LTD
Entity Type:Organization
Organization Name:RIVER VALLEY ORAL AND MAXILLOFACIAL SURGERY CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LUTCHKA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MD
Authorized Official - Phone:309-797-1770
Mailing Address - Street 1:930 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265
Mailing Address - Country:US
Mailing Address - Phone:309-797-1770
Mailing Address - Fax:309-797-1791
Practice Address - Street 1:930 16TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265
Practice Address - Country:US
Practice Address - Phone:309-797-1770
Practice Address - Fax:309-797-1791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty