Organization
PARK CITY DENTAL, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JASON M GRINTER DDS (PRESIDENT)
(815) 708-6556
Entity
Organization
Contact information
Practice address
555 N COURT ST, SUITE 100, ROCKFORD, IL 61103-6862
(815) 708-6556
(815) 708-6477
Mailing address
555 N COURT ST, SUITE 100, ROCKFORD, IL 61103-6862
(815) 708-6556
(815) 708-6477
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
019026609
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
091906609
—
IL
Enumeration date
12/11/2013
Last updated
12/11/2013
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