Provider Demographics
NPI:1912036385
Name:PRAIRIE CIRCLE DENTAL, P.C.
Entity Type:Organization
Organization Name:PRAIRIE CIRCLE DENTAL, P.C.
Other - Org Name:DR. RICHARD D. DAVIDSON
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-253-5216
Mailing Address - Street 1:703 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:TUSCOLA
Mailing Address - State:IL
Mailing Address - Zip Code:61953-1059
Mailing Address - Country:US
Mailing Address - Phone:217-253-5216
Mailing Address - Fax:217-253-4949
Practice Address - Street 1:703 N NILES AVE
Practice Address - Street 2:
Practice Address - City:TUSCOLA
Practice Address - State:IL
Practice Address - Zip Code:61953-1059
Practice Address - Country:US
Practice Address - Phone:217-253-5216
Practice Address - Fax:217-253-4949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center