Provider Demographics
NPI:1760667307
Name:BUFFALO PRAIRIE DENTAL CARE OF PITTSFIELD, INC
Entity Type:Organization
Organization Name:BUFFALO PRAIRIE DENTAL CARE OF PITTSFIELD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:NORTHCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-285-4084
Mailing Address - Street 1:850 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62363-1206
Mailing Address - Country:US
Mailing Address - Phone:217-285-4084
Mailing Address - Fax:
Practice Address - Street 1:850 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1206
Practice Address - Country:US
Practice Address - Phone:217-285-4084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190242471122300000X
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty