Provider Demographics
NPI:1841461845
Name:MILESTONE DENTAL CLINIC
Entity type:Organization
Organization Name:MILESTONE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-636-2801
Mailing Address - Street 1:275 N PHELPS AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2434
Mailing Address - Country:US
Mailing Address - Phone:815-484-8678
Mailing Address - Fax:815-484-8680
Practice Address - Street 1:275 NORTH PHELPS AVENUE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2434
Practice Address - Country:US
Practice Address - Phone:815-484-8678
Practice Address - Fax:815-484-8680
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILESTONE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL102303Medicaid