Provider Demographics
NPI:1760753362
Name:LJ DENTISTRY LLC
Entity Type:Organization
Organization Name:LJ DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:309-764-3242
Mailing Address - Street 1:2900 41ST ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-7823
Mailing Address - Country:US
Mailing Address - Phone:309-764-3242
Mailing Address - Fax:309-764-3267
Practice Address - Street 1:2900 41ST ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7823
Practice Address - Country:US
Practice Address - Phone:309-764-3242
Practice Address - Fax:309-764-3267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190264681223G0001X
IL190153831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty