Smalltown Dental Willow Knolls LLC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

Legal business name

SMALLTOWN DENTAL WILLOW KNOLLS LLC

Practice address

6712 N Mountello Dr
Peoria, IL 61614-2328

Phone

(309) 691-7855

NPI assigned

Jan 21, 2021

Organization subpart

Yes

Parent organization

SMALLTOWN DENTAL MANAGEMENT LLCAs reported in NPPES

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

Authorized official

Name

Luke Overcash

Title

Operations Manager

Phone

(309) 370-5853

Specialties & licenses 1

Addresses

Other names 1

• Smalltown Dental Willow Knolls Doing business as

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Michael Momchev, DDS

  • General Practice Dentistry
  • Peoria, IL
  • NPI 1063301000
  NPD
• Richard T Moon, DDS

  • General Practice Dentistry
  • Peoria, IL
  • NPI 1639220833
  NPD (past)

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

{
    "created_epoch": "1611187200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1611187200000",
    "number": "1699365809",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6712 N MOUNTELLO DR",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616142328",
            "telephone_number": "309-691-7855"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6712 N MOUNTELLO DR",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616142328",
            "telephone_number": "309-691-7855"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SMALLTOWN DENTAL WILLOW KNOLLS LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SMALLTOWN DENTAL MANAGEMENT LLC",
        "enumeration_date": "2021-01-21",
        "last_updated": "2021-01-21",
        "certification_date": "2021-01-21",
        "status": "A",
        "authorized_official_last_name": "OVERCASH",
        "authorized_official_first_name": "LUKE",
        "authorized_official_title_or_position": "OPERATIONS MANAGER",
        "authorized_official_telephone_number": "309-370-5853"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Smalltown Dental Willow Knolls",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Sue Ann Slusher, COTA/L
• James R Smalley, MD
• Smalltown Dental Glen LLC
• Smalltown Dental Peoria LLC
• Smalltown Dental River City PLLC
• Anna Carney Smarjesse
• Stephen J Smart, MD
• Lindsay Smick, CRNA
• Elizabeth S. Smid Garcia, PA
• Smith Surgical Supply Inc

• General Practice Dentistry in Peoria, IL
• Providers in Peoria, IL by specialty
• General Practice Dentistry in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 21, 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.