Provider Demographics
NPI:1407228513
Name:ROCKFORD DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:ROCKFORD DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMKE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:815-519-6218
Mailing Address - Street 1:6078 PALO VERDE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8117
Mailing Address - Country:US
Mailing Address - Phone:815-633-9864
Mailing Address - Fax:815-327-9160
Practice Address - Street 1:8100 FOREST HILLS RD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-2709
Practice Address - Country:US
Practice Address - Phone:815-633-9864
Practice Address - Fax:815-327-9160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026768122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty