Provider Demographics
NPI:1073108841
Name:SAUK TRAIL DENTAL CARE
Entity Type:Organization
Organization Name:SAUK TRAIL DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GARUBA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:708-608-3368
Mailing Address - Street 1:4343 SAUK TRL
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1254
Mailing Address - Country:US
Mailing Address - Phone:708-608-3368
Mailing Address - Fax:
Practice Address - Street 1:4343 SAUK TRL
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1254
Practice Address - Country:US
Practice Address - Phone:708-608-3368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-04
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty