Provider Demographics
NPI:1942605621
Name:MIDDLETON, JOHN ZACHARY (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ZACHARY
Last Name:MIDDLETON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 RADIO CITY DR
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-1569
Mailing Address - Country:US
Mailing Address - Phone:309-382-6404
Mailing Address - Fax:
Practice Address - Street 1:231 N BRUNS LN
Practice Address - Street 2:BLDG C
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4612
Practice Address - Country:US
Practice Address - Phone:217-546-9097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029902122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist