Provider Demographics
NPI:1649308230
Name:TAZEWELL COUNTY HEALTH DEPARTMENT -DENTAL HEALTH CENTER
Entity type:Organization
Organization Name:TAZEWELL COUNTY HEALTH DEPARTMENT -DENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF DENTAL SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:309-382-2229
Mailing Address - Street 1:135 RADIO CITY DRIVE
Mailing Address - Street 2:SUITE A & B
Mailing Address - City:NORTH PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554
Mailing Address - Country:US
Mailing Address - Phone:309-382-2229
Mailing Address - Fax:309-382-1155
Practice Address - Street 1:135 RADIO CITY DRIVE
Practice Address - Street 2:SUITE A & B
Practice Address - City:NORTH PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554
Practice Address - Country:US
Practice Address - Phone:309-382-2229
Practice Address - Fax:309-382-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILE9993-0978-05251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare