NPIMap

Organization Active NPI

Central Illinois Center for TMJ and Facial Pain, P.C.

  • Dentist
  • East Peoria, IL
National Provider Identifier
1346546421
Registry record updated Sep 30, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
019021995 Issued in IL
Legal business name
CENTRAL ILLINOIS CENTER FOR TMJ AND FACIAL PAIN, P.C.
Practice address
731 Sabrina Dr
Suite a
East Peoria, IL 61611-3581
Phone
(309) 699-1300
NPI assigned
Feb 7, 2011
Last updated
Sep 30, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 30, 2013

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

Authorized official

Name
Dr. Jack Glenn Walz, DDSNPI 1427166008
Title
Provider
Phone
(309) 699-1300

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dentist 122300000X 019021995 IL Primary

Addresses

Primary practice location

731 Sabrina Dr
Suite a
East Peoria, IL 61611-3581

Mailing address

731 Sabrina Dr
Suite a
East Peoria, IL 61611-3581
Phone (309) 699-1300

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110224000303 IL DME Supplier - Oral Surgery - Dentist 7719168731 Practice locations: East Peoria, IL

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Central Illinois Center for TMJ and Facial Pain PC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1297036800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1380499200000",
    "number": "1346546421",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "731 SABRINA DR",
            "address_2": "SUITE A",
            "city": "EAST PEORIA",
            "state": "IL",
            "postal_code": "616113581",
            "telephone_number": "309-699-1300"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "731 SABRINA DR",
            "address_2": "SUITE A",
            "city": "EAST PEORIA",
            "state": "IL",
            "postal_code": "616113581",
            "telephone_number": "309-699-1300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTRAL ILLINOIS CENTER FOR TMJ AND FACIAL PAIN, P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-02-07",
        "last_updated": "2013-09-30",
        "status": "A",
        "authorized_official_last_name": "WALZ",
        "authorized_official_first_name": "JACK",
        "authorized_official_middle_name": "GLENN",
        "authorized_official_title_or_position": "PROVIDER",
        "authorized_official_telephone_number": "309-699-1300",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "IL",
            "license": "019021995",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in East Peoria, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 30, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.