Provider Demographics
NPI:1295204220
Name:DENTAL TOWN LTD
Entity Type:Organization
Organization Name:DENTAL TOWN LTD
Other - Org Name:DENTAL TOWN LITTLE VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-713-5000
Mailing Address - Street 1:6283 S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2505
Mailing Address - Country:US
Mailing Address - Phone:708-713-5000
Mailing Address - Fax:708-713-5000
Practice Address - Street 1:6283 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2505
Practice Address - Country:US
Practice Address - Phone:708-416-8000
Practice Address - Fax:708-416-8000
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL TOWN LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-20
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty