Provider Demographics
NPI:1811379142
Name:ROCK RIVER ORAL SURGERY & DENTAL IMPLANT CENTER LLC
Entity type:Organization
Organization Name:ROCK RIVER ORAL SURGERY & DENTAL IMPLANT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCUE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-399-1234
Mailing Address - Street 1:973 FEATHERSTONE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5912
Mailing Address - Country:US
Mailing Address - Phone:815-399-1234
Mailing Address - Fax:815-399-2423
Practice Address - Street 1:973 FEATHERSTONE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5912
Practice Address - Country:US
Practice Address - Phone:815-399-1234
Practice Address - Fax:815-399-2423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI019030148261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery