Provider Demographics
NPI:1053565218
Name:BACK, BRIAN C (DMD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
Last Name:BACK
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 1:104 E MAIN ST
Mailing Address - Street 2:P.O. BOX 142
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-2135
Mailing Address - Country:US
Mailing Address - Phone:618-566-7384
Mailing Address - Fax:618-566-4290
Practice Address - Street 1:104 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-2135
Practice Address - Country:US
Practice Address - Phone:618-566-7384
Practice Address - Fax:618-566-4290
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190277921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice