Provider Demographics
NPI:1649342999
Name:SPRINGFIELD PERIODONTICS LLC
Entity type:Organization
Organization Name:SPRINGFIELD PERIODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-787-6761
Mailing Address - Street 1:2025 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4190
Mailing Address - Country:US
Mailing Address - Phone:217-787-6761
Mailing Address - Fax:217-787-6611
Practice Address - Street 1:2025 W ILES AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4190
Practice Address - Country:US
Practice Address - Phone:217-787-6761
Practice Address - Fax:217-787-6611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty