| Park City Dental, Pc | |
|
555 N Court St Suite 100 Rockford IL 61103-6862 | |
| (815) 708-6556 | |
| (815) 708-6477 |
| Full Name | Park City Dental, Pc |
|---|---|
| Speciality | Dentist |
| Location | 555 N Court St, Rockford, Illinois |
| Authorized Official Name and Position | Jason M Grinter (PRESIDENT) |
| Authorized Official Contact | 8157086556 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Park City Dental, Pc 555 N Court St Suite 100 Rockford IL 61103-6862 Ph: (815) 708-6556 | Park City Dental, Pc 555 N Court St Suite 100 Rockford IL 61103-6862 Ph: (815) 708-6556 |
| NPI Number | 1225469596 |
|---|---|
| Provider Enumeration Date | 12/11/2013 |
| Last Update Date | 12/11/2013 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1225469596 | NPI | - | NPPES |
| 091906609 | Medicaid | IL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | 019026609 (Illinois) | Primary |
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