Provider Demographics
NPI:1295988574
Name:PERIODONTICS OF ROCKFORD LTD.
Entity type:Organization
Organization Name:PERIODONTICS OF ROCKFORD LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:VA
Authorized Official - Last Name:BURCH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:815-227-5858
Mailing Address - Street 1:1055 FEATHERSTONE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107
Mailing Address - Country:US
Mailing Address - Phone:815-227-5858
Mailing Address - Fax:815-227-6238
Practice Address - Street 1:1055 FEATHERSTONE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107
Practice Address - Country:US
Practice Address - Phone:815-227-5858
Practice Address - Fax:815-227-6238
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERIODONTICS OF ROCKFORD LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021002217122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty