Provider Demographics
NPI:1114407970
Name:EP DENTAL SLEEP MEDICINE, PLLC
Entity Type:Organization
Organization Name:EP DENTAL SLEEP MEDICINE, PLLC
Other - Org Name:KOALA CENTER FOR SLEEP DISORDERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KALISH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:915-881-9898
Mailing Address - Street 1:11825 STATE ROUTE 40 STE 100
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-8842
Mailing Address - Country:US
Mailing Address - Phone:309-839-9971
Mailing Address - Fax:
Practice Address - Street 1:6901 HELEN OF TROY STE D2
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79911-3130
Practice Address - Country:US
Practice Address - Phone:815-881-9898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-20
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23551122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty