Provider Demographics
NPI:1083069199
Name:DENTAL LOFT - THE LOOP
Entity Type:Organization
Organization Name:DENTAL LOFT - THE LOOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KILEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HIRONS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-482-0702
Mailing Address - Street 1:1 W HARRIS AVE STE 2A
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2497
Mailing Address - Country:US
Mailing Address - Phone:708-482-0702
Mailing Address - Fax:
Practice Address - Street 1:111 W WASHINGTON ST
Practice Address - Street 2:SUITE 1350
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-2703
Practice Address - Country:US
Practice Address - Phone:708-482-0702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.027663122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty