Provider Demographics
NPI:1467674770
Name:BLOOMINGTON FAMILY DENTAL, LTD.
Entity Type:Organization
Organization Name:BLOOMINGTON FAMILY DENTAL, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:VAN SCOYOC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-664-0570
Mailing Address - Street 1:908 N HERSHEY RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3730
Mailing Address - Country:US
Mailing Address - Phone:309-664-0570
Mailing Address - Fax:309-664-6612
Practice Address - Street 1:908 N HERSHEY RD
Practice Address - Street 2:SUITE 2
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3730
Practice Address - Country:US
Practice Address - Phone:309-664-0570
Practice Address - Fax:309-664-6612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty