Provider Demographics
NPI:1235876814
Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Other - Org Name:CREATING SMILES COSMETIC AND FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTEITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-540-8306
Mailing Address - Street 1:101 UNITED DR STE 150
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-7439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 UNITED DR STE 150
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-7439
Practice Address - Country:US
Practice Address - Phone:618-345-7676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-16
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty