Provider Demographics
NPI:1215579008
Name:MGM19 INC
Entity Type:Organization
Organization Name:MGM19 INC
Other - Org Name:MCKNIGHT ORAL, MAXILLOFACIAL AND DENTAL IMPLANT SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:MCKNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:630-377-7077
Mailing Address - Street 1:605 COURTYARD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1463
Mailing Address - Country:US
Mailing Address - Phone:630-377-7077
Mailing Address - Fax:
Practice Address - Street 1:605 COURTYARD DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1463
Practice Address - Country:US
Practice Address - Phone:630-377-7077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-13
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL021.002827OtherSPECIALIST LICENSE DENTISTRY
IL036.144437OtherMEDICAL LICENSE
IL1518250125OtherNPI
IL019.029613OtherDENTAL LICENSE