Provider Demographics
NPI:1366710410
Name:IIDSM BLOOMINGTON LLC
Entity type:Organization
Organization Name:IIDSM BLOOMINGTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS RECEIVABLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAILIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-243-1341
Mailing Address - Street 1:11825 STATE ROUTE 40
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-8842
Mailing Address - Country:US
Mailing Address - Phone:309-243-1341
Mailing Address - Fax:309-240-0351
Practice Address - Street 1:2309 E EMPIRE ST
Practice Address - Street 2:500
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8636
Practice Address - Country:US
Practice Address - Phone:309-319-6568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty