Provider Demographics
NPI:1649592353
Name:TWO RIVERS PEDIATRIC DENTISTRY, L.L.C.
Entity Type:Organization
Organization Name:TWO RIVERS PEDIATRIC DENTISTRY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-797-3020
Mailing Address - Street 1:1872 AVENUE OF THE CITIES
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-4878
Mailing Address - Country:US
Mailing Address - Phone:309-797-3020
Mailing Address - Fax:309-797-3212
Practice Address - Street 1:1872 AVENUE OF THE CITIES
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265
Practice Address - Country:US
Practice Address - Phone:309-797-3020
Practice Address - Fax:309-797-3212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025264122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty