Provider Demographics
NPI:1376014746
Name:EAST MOLINE DENTAL CENTER PC
Entity Type:Organization
Organization Name:EAST MOLINE DENTAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:KENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-755-1700
Mailing Address - Street 1:748 GREEN PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLONA
Mailing Address - State:IL
Mailing Address - Zip Code:61241-9617
Mailing Address - Country:US
Mailing Address - Phone:309-792-2211
Mailing Address - Fax:309-792-4678
Practice Address - Street 1:748 GREEN PARK AVE
Practice Address - Street 2:
Practice Address - City:COLONA
Practice Address - State:IL
Practice Address - Zip Code:61241-9617
Practice Address - Country:US
Practice Address - Phone:309-792-2211
Practice Address - Fax:309-792-4678
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST MOLINE DENTAL CENTER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty