Provider Demographics
NPI:1386982940
Name:ROCKFORD FAMILY DENTAL P.C.
Entity type:Organization
Organization Name:ROCKFORD FAMILY DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAZVAN
Authorized Official - Middle Name:CORNEL
Authorized Official - Last Name:MIRZA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-964-8713
Mailing Address - Street 1:2715 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3111
Mailing Address - Country:US
Mailing Address - Phone:815-964-8713
Mailing Address - Fax:815-964-3719
Practice Address - Street 1:2715 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3111
Practice Address - Country:US
Practice Address - Phone:815-964-8713
Practice Address - Fax:815-964-3719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-16
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty