Provider Demographics
NPI:1790872117
Name:QUAD CITY ORTHODONTIC GROUP, LLC
Entity Type:Organization
Organization Name:QUAD CITY ORTHODONTIC GROUP, LLC
Other - Org Name:QUAD CITY ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:BRONWEN
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:309-786-7782
Mailing Address - Street 1:2850 24TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5308
Mailing Address - Country:US
Mailing Address - Phone:309-786-7782
Mailing Address - Fax:309-786-5829
Practice Address - Street 1:2850 24TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5308
Practice Address - Country:US
Practice Address - Phone:309-786-7782
Practice Address - Fax:309-786-5829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty