Provider Demographics
NPI:1033305511
Name:HENRY J ANTOLAK DMD PC
Entity Type:Organization
Organization Name:HENRY J ANTOLAK DMD PC
Other - Org Name:FORUM DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-364-1821
Mailing Address - Street 1:1810 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-4603
Mailing Address - Country:US
Mailing Address - Phone:573-364-1821
Mailing Address - Fax:
Practice Address - Street 1:1810 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4603
Practice Address - Country:US
Practice Address - Phone:573-364-1821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE13190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty