Provider Demographics
NPI:1306217252
Name:ILLINOIS DENTAL PROVIDERS (GLEN ELLYN), LTD
Entity Type:Organization
Organization Name:ILLINOIS DENTAL PROVIDERS (GLEN ELLYN), LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NITTINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-755-0816
Mailing Address - Street 1:7160 DALLAS PKWY STE 400
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-7111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5805
Practice Address - Country:US
Practice Address - Phone:630-790-8430
Practice Address - Fax:216-584-1056
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTALONE PARTNERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-16
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty