Provider Demographics
NPI:1285202978
Name:FAMILIA DENTAL RIVER GLEN LLC
Entity Type:Organization
Organization Name:FAMILIA DENTAL RIVER GLEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING & PRAYER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:847-453-7396
Mailing Address - Street 1:2050 E ALGONQUIN RD STE 610
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4166
Mailing Address - Country:US
Mailing Address - Phone:847-453-7396
Mailing Address - Fax:847-453-7396
Practice Address - Street 1:142 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1206
Practice Address - Country:US
Practice Address - Phone:414-444-1823
Practice Address - Fax:414-963-1163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental