NPIMap

Organization Active NPI

Custom Dental Care, P.C.

  • Dentist
  • Quincy, IL
National Provider Identifier
1932452893
Registry record updated Oct 17, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
019027406 Issued in IL
Legal business name
CUSTOM DENTAL CARE, P.C.
Practice address
3740 E Lake Ctr Ste B
Quincy, IL 62305-5805
Phone
(217) 214-4545
Fax
(217) 214-4546
NPI assigned
Oct 17, 2012
Last updated
Oct 17, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 17, 2012

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

Authorized official

Name
Dr. Dennis Ryan Wagner, D.M.D.
Title
Owner/President
Phone
(217) 430-1429

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dentist 122300000X 019027406 IL Primary

Addresses

Primary practice location

3740 E Lake Ctr Ste B
Quincy, IL 62305-5805

Mailing address

3740 E Lake Ctr Ste B
Quincy, IL 62305-5805
Phone (217) 214-4545

National Provider Directory

National Provider Directory

Locations

3740 E Lake Ctr
Ste B
Quincy, IL 62305
Phone (217) 214-4545

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": "1350432000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1350432000000",
    "number": "1932452893",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3740 E LAKE CTR STE B",
            "city": "QUINCY",
            "state": "IL",
            "postal_code": "623055805",
            "telephone_number": "217-214-4545",
            "fax_number": "217-214-4546"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3740 E LAKE CTR STE B",
            "city": "QUINCY",
            "state": "IL",
            "postal_code": "623055805",
            "telephone_number": "217-214-4545",
            "fax_number": "217-214-4546"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CUSTOM DENTAL CARE, P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-17",
        "last_updated": "2012-10-17",
        "status": "A",
        "authorized_official_last_name": "WAGNER",
        "authorized_official_first_name": "DENNIS",
        "authorized_official_middle_name": "RYAN",
        "authorized_official_title_or_position": "OWNER/PRESIDENT",
        "authorized_official_telephone_number": "217-430-1429",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.M.D."
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "IL",
            "license": "019027406",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Quincy, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 17, 2012; 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.