Organization
ASSOCIATED ORAL AND MAXILLOFACIAL SURGEONS OF PEORIA, LTD
Active
Other names
Associated Oral Surgeons
Organization subpart
No
Provider details
NPI number
Authorized official
ROBYN WOLFE (PRACTICE LEADER)
(309) 682-1249
Entity
Organization
Contact information
Practice address
5720 N KNOXVILLE AVE, PEORIA, IL 61614-4331
(309) 682-1213
(309) 682-5386
Mailing address
5720 N KNOXVILLE AVE, PEORIA, IL 61614-4331
(309) 682-1213
(309) 682-5386
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
019023700
IL
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
019024407
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
019023700
JOHN J. OTTEN LICENSE NUM
IL
01
—
019024407
LARRY D. OTTE LICENSE NUM
IL
Enumeration date
06/23/2006
Last updated
11/05/2024
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