Provider Demographics
NPI:1154357291
Name:ASSOCIATED ORAL AND MAXILLOFACIAL SURGEONS OF PEORIA, LTD
Entity type:Organization
Organization Name:ASSOCIATED ORAL AND MAXILLOFACIAL SURGEONS OF PEORIA, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE LEADER
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-682-1249
Mailing Address - Street 1:5720 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4331
Mailing Address - Country:US
Mailing Address - Phone:309-682-1213
Mailing Address - Fax:309-682-5386
Practice Address - Street 1:5720 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4331
Practice Address - Country:US
Practice Address - Phone:309-682-1213
Practice Address - Fax:309-682-5386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190237001223S0112X
IL0190244071223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019024407OtherLARRY D. OTTE LICENSE NUM
IL019023700OtherJOHN J. OTTEN LICENSE NUM