Provider Demographics
NPI:1033383567
Name:ASSOCIATED DENTAL SPECIALISTS OF LONG GROVE LTD
Entity Type:Organization
Organization Name:ASSOCIATED DENTAL SPECIALISTS OF LONG GROVE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-634-6166
Mailing Address - Street 1:RFD 4160
Mailing Address - Street 2:GROVE MEDICAL CENTER SUITE 308
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-9586
Mailing Address - Country:US
Mailing Address - Phone:847-634-6166
Mailing Address - Fax:846-634-6302
Practice Address - Street 1:RFD 4160
Practice Address - Street 2:GROVE MEDICAL CENTER SUITE 308
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-9586
Practice Address - Country:US
Practice Address - Phone:847-634-6166
Practice Address - Fax:846-634-6302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060.003411019.0215331223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty