Provider Demographics
NPI: | 1932452893 |
---|---|
Name: | CUSTOM DENTAL CARE, P.C. |
Entity Type: | Organization |
Organization Name: | CUSTOM DENTAL CARE, P.C. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER/PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | DENNIS |
Authorized Official - Middle Name: | RYAN |
Authorized Official - Last Name: | WAGNER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 217-430-1429 |
Mailing Address - Street 1: | 3740 E LAKE CTR STE B |
Mailing Address - Street 2: | |
Mailing Address - City: | QUINCY |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 62305-5805 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 217-214-4545 |
Mailing Address - Fax: | 217-214-4546 |
Practice Address - Street 1: | 3740 E LAKE CTR STE B |
Practice Address - Street 2: | |
Practice Address - City: | QUINCY |
Practice Address - State: | IL |
Practice Address - Zip Code: | 62305-5805 |
Practice Address - Country: | US |
Practice Address - Phone: | 217-214-4545 |
Practice Address - Fax: | 217-214-4546 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-10-17 |
Last Update Date: | 2012-10-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 019027406 | 122300000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122300000X | Dental Providers | Dentist | Group - Single Specialty |