Provider Demographics
NPI:1346563525
Name:MODERN DENTAL OF ROCKFORD LLC
Entity Type:Organization
Organization Name:MODERN DENTAL OF ROCKFORD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-532-4902
Mailing Address - Street 1:1321 SANDY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61109-2120
Mailing Address - Country:US
Mailing Address - Phone:815-209-9070
Mailing Address - Fax:
Practice Address - Street 1:1321 SANDY HOLLOW RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-2120
Practice Address - Country:US
Practice Address - Phone:815-209-9070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty