Provider Demographics
NPI:1588818736
Name:EDWARD L RICK DDS,MS,PC
Entity Type:Organization
Organization Name:EDWARD L RICK DDS,MS,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOSKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-682-5863
Mailing Address - Street 1:6926 N UNIVERSITY ST STE C
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1728
Mailing Address - Country:US
Mailing Address - Phone:309-692-5863
Mailing Address - Fax:309-689-3031
Practice Address - Street 1:6926 N UNIVERSITY ST STE C
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1728
Practice Address - Country:US
Practice Address - Phone:309-692-5863
Practice Address - Fax:309-689-3031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021-0008851223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003466/101355Medicaid