Provider Demographics
NPI:1003370248
Name:BOLINGBROOK DENTAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:BOLINGBROOK DENTAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:G
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-465-8627
Mailing Address - Street 1:391 QUADRANGLE DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-3442
Mailing Address - Country:US
Mailing Address - Phone:630-759-4400
Mailing Address - Fax:
Practice Address - Street 1:391 QUADRANGLE DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3442
Practice Address - Country:US
Practice Address - Phone:630-759-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental