Decatur 2012 LLC

Primary specialty

Dental Clinic/CenterTaxonomy code 261QD0000X

Legal business name

DECATUR 2012 LLC

Doing business as

Family Dental

Practice address

141 E Pershing Rd
Decatur, IL 62526-3213

Phone

(888) 988-4066

Fax

(847) 496-7603

NPI assigned

Jun 5, 2012

Last updated

Oct 15, 2021By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Brandon Alexander Taylor, CPCS

Title

Credentialing Payer Relations MGR

Phone

(847) 453-7396

Specialties & licenses 1

Addresses

Other names 1

• Family Dental Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1338854400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1634256000000",
    "number": "1306107578",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2050 E ALGONQUIN RD",
            "address_2": "SUITE 610",
            "city": "SCHAUMBURG",
            "state": "IL",
            "postal_code": "601734144",
            "telephone_number": "888-988-8406",
            "fax_number": "847-496-7603"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "141 E PERSHING RD",
            "city": "DECATUR",
            "state": "IL",
            "postal_code": "625263213",
            "telephone_number": "888-988-4066",
            "fax_number": "847-496-7603"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DECATUR 2012 LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-06-05",
        "last_updated": "2021-10-15",
        "certification_date": "2021-10-15",
        "status": "A",
        "authorized_official_last_name": "TAYLOR",
        "authorized_official_first_name": "BRANDON",
        "authorized_official_middle_name": "ALEXANDER",
        "authorized_official_title_or_position": "CREDENTIALING PAYER RELATIONS MGR",
        "authorized_official_telephone_number": "847-453-7396",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CPCS"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Family Dental",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Kelli Ann Daugherty, CNM, APRN
• James E Davis Jr., O.D.
• Mohammed Dawood, M.D.
• Carlton Dean, PHARM.D.
• Zaria Deberry
• Decatur 2013 LLC
• Decatur 2014
• Decatur 2015 LLC
• Decatur 2016 LLC
• Decatur Ambulance Service, Inc.

• Dental Clinic/Center in Decatur, IL
• Providers in Decatur, IL by specialty
• Dental Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 15, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.