Provider Demographics
NPI:1619311248
Name:ILLINOIS INSTITUTE OF DENTAL SLEEP MEDICINE INC
Entity Type:Organization
Organization Name:ILLINOIS INSTITUTE OF DENTAL SLEEP MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-282-8565
Mailing Address - Street 1:11825 STATE ROUTE 40
Mailing Address - Street 2:100
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-8842
Mailing Address - Country:US
Mailing Address - Phone:309-282-8565
Mailing Address - Fax:309-265-0156
Practice Address - Street 1:11825 STATE ROUTE 40 STE 100
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525-8842
Practice Address - Country:US
Practice Address - Phone:309-243-8980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILLINOIS INSTITUTE OF DENTAL SLEEP MEDICINE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-25
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.019599122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty