Provider Demographics
NPI:1477824977
Name:AFFORDABLE DENTURES- PEORIA, P.C
Entity Type:Organization
Organization Name:AFFORDABLE DENTURES- PEORIA, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-689-1452
Mailing Address - Street 1:2807 W TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1557
Mailing Address - Country:US
Mailing Address - Phone:309-689-1452
Mailing Address - Fax:
Practice Address - Street 1:2807 W TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1557
Practice Address - Country:US
Practice Address - Phone:309-689-1452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.018482122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty