Provider Demographics
NPI:1053893586
Name:KNOX FAMILY DENTAL LLC
Entity type:Organization
Organization Name:KNOX FAMILY DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETOSKEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-738-6224
Mailing Address - Street 1:1172 MONROE ST STE 7
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2554
Mailing Address - Country:US
Mailing Address - Phone:309-343-9229
Mailing Address - Fax:
Practice Address - Street 1:1172 MONROE ST STE 7
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2554
Practice Address - Country:US
Practice Address - Phone:309-343-9229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030409261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental