Provider Demographics
NPI:1225493034
Name:ANDRIS FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:ANDRIS FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:309-263-8317
Mailing Address - Street 1:636 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-1581
Mailing Address - Country:US
Mailing Address - Phone:309-263-8317
Mailing Address - Fax:309-263-2175
Practice Address - Street 1:636 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-1581
Practice Address - Country:US
Practice Address - Phone:309-263-8317
Practice Address - Fax:309-263-2175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.029393261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental