Provider Demographics
NPI:1184033839
Name:DENTAL ON 45 INC
Entity Type:Organization
Organization Name:DENTAL ON 45 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-541-4066
Mailing Address - Street 1:34484 N US HIGHWAY 45
Mailing Address - Street 2:SUITE C
Mailing Address - City:THIRD LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-4038
Mailing Address - Country:US
Mailing Address - Phone:224-541-4066
Mailing Address - Fax:847-752-8425
Practice Address - Street 1:34484 N US HIGHWAY 45
Practice Address - Street 2:SUITE C
Practice Address - City:THIRD LAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-4038
Practice Address - Country:US
Practice Address - Phone:224-541-4066
Practice Address - Fax:847-752-8425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty