Provider Demographics
NPI:1083068670
Name:DENTAL PROFESSIONALS OF ILLINOIS, PC
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF ILLINOIS, PC
Other - Org Name:DENTAL CARE OF HUNTLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:W
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8312
Mailing Address - Street 1:12222 ROUTE 47
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12222 ROUTE 47
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142
Practice Address - Country:US
Practice Address - Phone:224-293-0137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF ILLINOIS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty