Provider Demographics
NPI:1932452893
Name:CUSTOM DENTAL CARE, P.C.
Entity type:Organization
Organization Name:CUSTOM DENTAL CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-430-1429
Mailing Address - Street 1:3740 E LAKE CTR STE B
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-5805
Mailing Address - Country:US
Mailing Address - Phone:217-214-4545
Mailing Address - Fax:217-214-4546
Practice Address - Street 1:3740 E LAKE CTR STE B
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-5805
Practice Address - Country:US
Practice Address - Phone:217-214-4545
Practice Address - Fax:217-214-4546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027406122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty