Provider Demographics
NPI:1871190884
Name:MOSQUERA CASTRILLON, JORGE ENRIQUE (DDS)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ENRIQUE
Last Name:MOSQUERA CASTRILLON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 SANDPIPER DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-6722
Mailing Address - Country:US
Mailing Address - Phone:561-635-8018
Mailing Address - Fax:
Practice Address - Street 1:687 E LINTON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5902
Practice Address - Country:US
Practice Address - Phone:718-909-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019032932122300000X
IL0210030811223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0700XDental ProvidersDentistProsthodontics