Provider Demographics
NPI:1043609167
Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Other - Org Name:MOKENA CROSSINGS FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED SUPERIVOSR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:9990 W 190TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8188
Mailing Address - Country:US
Mailing Address - Phone:708-479-9797
Mailing Address - Fax:708-478-4571
Practice Address - Street 1:9990 W 190TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8188
Practice Address - Country:US
Practice Address - Phone:708-479-9797
Practice Address - Fax:708-478-4571
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty