Provider Demographics
NPI:1235444639
Name:INNOVATIVE DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:INNOVATIVE DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DIMPLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TEJANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-368-6400
Mailing Address - Street 1:20 E WASHINGTON ST
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602
Mailing Address - Country:US
Mailing Address - Phone:312-368-6400
Mailing Address - Fax:
Practice Address - Street 1:20 E WASHINGTON ST
Practice Address - Street 2:SUITE 1300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602
Practice Address - Country:US
Practice Address - Phone:312-368-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty