Provider Demographics
NPI:1043527351
Name:COVINGTON FAMILY DENTAL, INC
Entity Type:Organization
Organization Name:COVINGTON FAMILY DENTAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:QUN
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-828-0213
Mailing Address - Street 1:1355 GAIL DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1141
Mailing Address - Country:US
Mailing Address - Phone:847-828-0213
Mailing Address - Fax:
Practice Address - Street 1:300 PIKE ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-2127
Practice Address - Country:US
Practice Address - Phone:859-491-7453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100138020Medicaid