Provider Demographics
NPI:1174851539
Name:1ST FAMILY DENTAL OF FOX VALLEY, INC.
Entity Type:Organization
Organization Name:1ST FAMILY DENTAL OF FOX VALLEY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VESNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BELKIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-340-8318
Mailing Address - Street 1:5333 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2121
Mailing Address - Country:US
Mailing Address - Phone:773-728-5333
Mailing Address - Fax:773-739-4300
Practice Address - Street 1:55 S COMMONS DR STE 102
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4433
Practice Address - Country:US
Practice Address - Phone:630-585-1155
Practice Address - Fax:630-585-1164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-24
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026635122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty