Provider Demographics
NPI:1316120033
Name:QUINCY ORAL & MAXILLOFACIAL SURGERY, P.C.
Entity type:Organization
Organization Name:QUINCY ORAL & MAXILLOFACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-222-9434
Mailing Address - Street 1:3915 MAINE ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-5843
Mailing Address - Country:US
Mailing Address - Phone:217-222-9434
Mailing Address - Fax:217-222-0671
Practice Address - Street 1:3915 MAINE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-5843
Practice Address - Country:US
Practice Address - Phone:217-222-9434
Practice Address - Fax:217-222-0671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207455Medicare PIN