Active NPI
Taylor Pham
- Dentist
- East Peoria, IL
National Provider Identifier
1124689138
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 019032199
- Practice address
- 368 W Washington St
East Peoria, IL 61611-2036 - Phone
- (309) 694-4444
- NPI assigned
- Jun 21, 2019
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 019032199 | IL | Primary |
Addresses
Primary practice location
368 W Washington St
East Peoria, IL 61611-2036
Mailing address
368 W Washington St
East Peoria, IL 61611-2036
Phone (309) 694-4444
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019032199 | IL | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Dental Professionals of Illinois, P.C. | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
dba Family Dental Care of East Peoria
- General Practice Dentistry
- East Peoria, IL
- NPI 1386985380
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1561075200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1561075200000",
"number": "1124689138",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "368 W WASHINGTON ST",
"city": "EAST PEORIA",
"state": "IL",
"postal_code": "616112036",
"telephone_number": "309-694-4444"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "368 W WASHINGTON ST",
"city": "EAST PEORIA",
"state": "IL",
"postal_code": "616112036",
"telephone_number": "309-694-4444"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PHAM",
"first_name": "TAYLOR",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2019-06-21",
"last_updated": "2019-06-21",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "IL",
"license": "019032199",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in East Peoria, IL
- Peoria Treatment Center, LLC (MedMark Treatment Centers East Peoria)
- Julie Perino
- Petersen Health Operations (Fondulac Rehabilitation & Health Care Center)
- Petersen Health Operations, LLC (Fondulac Rehabilitation & Health Care Center)
- Steven Petri
- Tony Pham
- Jonathan Phen
- Phillips Investments, LLC - East Peoria Operation Series
- Taylor Phillips, PHARMD
- Kaylee Elizabeth Polen, FNP-C
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 21, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.