Provider Demographics
NPI:1407866452
Name:BUFFALO PRAIRIE DENTAL CARE OF QUINCY, INC
Entity Type:Organization
Organization Name:BUFFALO PRAIRIE DENTAL CARE OF QUINCY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:K
Authorized Official - Middle Name:J
Authorized Official - Last Name:STURHAHN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-224-7645
Mailing Address - Street 1:2801 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3639
Mailing Address - Country:US
Mailing Address - Phone:217-224-7645
Mailing Address - Fax:217-224-8465
Practice Address - Street 1:2801 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3639
Practice Address - Country:US
Practice Address - Phone:217-224-7645
Practice Address - Fax:217-224-8465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190242471122300000X
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty