Provider Demographics
NPI:1578117339
Name:DANIEL, ALEX MCCOY (DMD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:MCCOY
Last Name:DANIEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 HAMPSTEAD DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-2206
Mailing Address - Country:US
Mailing Address - Phone:630-608-7428
Mailing Address - Fax:
Practice Address - Street 1:6215 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2514
Practice Address - Country:US
Practice Address - Phone:815-399-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.032375122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program