Provider Demographics
NPI:1336445253
Name:MCCUAN, RONNIE (DMD, JD)
Entity Type:Individual
Prefix:DR
First Name:RONNIE
Middle Name:
Last Name:MCCUAN
Suffix:
Gender:M
Credentials:DMD, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S CAPITOL ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-2201
Mailing Address - Country:US
Mailing Address - Phone:618-294-4028
Mailing Address - Fax:
Practice Address - Street 1:700 LOGAN COLLEGE DR
Practice Address - Street 2:DENTAL HYGIENE PROGRAM
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-2500
Practice Address - Country:US
Practice Address - Phone:618-985-3741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-10
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190182741223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health