Provider Demographics
NPI:1053427534
Name:RODEFFER, MAX (DMD)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:RODEFFER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:IL
Mailing Address - Zip Code:62341-1436
Mailing Address - Country:US
Mailing Address - Phone:217-847-3900
Mailing Address - Fax:217-847-6684
Practice Address - Street 1:911 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:IL
Practice Address - Zip Code:62341-1436
Practice Address - Country:US
Practice Address - Phone:217-847-3900
Practice Address - Fax:217-847-6684
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist