Provider Demographics
NPI:1245617570
Name:WEST SIDE FAMILY DENTISTRY, LTD
Entity Type:Organization
Organization Name:WEST SIDE FAMILY DENTISTRY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KERI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-539-7004
Mailing Address - Street 1:709 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-2457
Mailing Address - Country:US
Mailing Address - Phone:815-539-7004
Mailing Address - Fax:815-539-7060
Practice Address - Street 1:709 PLAZA DR
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-2457
Practice Address - Country:US
Practice Address - Phone:815-539-7004
Practice Address - Fax:815-539-7060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-06
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0255311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty