Provider Demographics
NPI:1457801755
Name:FOREST CITY DENTAL PC
Entity Type:Organization
Organization Name:FOREST CITY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RANDOL
Authorized Official - Last Name:STOVALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-397-7454
Mailing Address - Street 1:1855 DAIMLER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61112-1063
Mailing Address - Country:US
Mailing Address - Phone:815-397-7454
Mailing Address - Fax:815-397-7555
Practice Address - Street 1:1855 DAIMLER RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61112-1063
Practice Address - Country:US
Practice Address - Phone:815-397-7454
Practice Address - Fax:815-397-7555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026159122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty