Provider Demographics
NPI:1124549399
Name:IVORY DENTAL
Entity Type:Organization
Organization Name:IVORY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEFALI
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-577-0900
Mailing Address - Street 1:12624 S ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-5448
Mailing Address - Country:US
Mailing Address - Phone:815-577-0900
Mailing Address - Fax:
Practice Address - Street 1:12624 S ROUTE 59
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-5448
Practice Address - Country:US
Practice Address - Phone:815-577-0900
Practice Address - Fax:815-577-6331
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVORY DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190258241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1043387707OtherTYPE I