Provider Demographics
NPI:1710149976
Name:WOODRUFF, DAVID LAWRENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LAWRENCE
Last Name:WOODRUFF
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 W GLEN AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4690
Mailing Address - Country:US
Mailing Address - Phone:309-673-4616
Mailing Address - Fax:309-673-6089
Practice Address - Street 1:2015 W GLEN AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4690
Practice Address - Country:US
Practice Address - Phone:309-673-4616
Practice Address - Fax:309-673-6089
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019019595122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist