Provider Demographics
NPI:1336477769
Name:ROCKRIVER DENTAL LLC
Entity Type:Organization
Organization Name:ROCKRIVER DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-965-5555
Mailing Address - Street 1:318 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2922
Mailing Address - Country:US
Mailing Address - Phone:815-965-5555
Mailing Address - Fax:815-965-5561
Practice Address - Street 1:318 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2922
Practice Address - Country:US
Practice Address - Phone:815-965-5555
Practice Address - Fax:815-965-5561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-23
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190196031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty