Provider Demographics
NPI:1306853429
Name:WINTHROP HARBOR DENTAL CENTER
Entity Type:Organization
Organization Name:WINTHROP HARBOR DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:OPELT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-872-5626
Mailing Address - Street 1:644 SHERIDAN RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WINTHROP HARBOR
Mailing Address - State:IL
Mailing Address - Zip Code:60096-1350
Mailing Address - Country:US
Mailing Address - Phone:847-872-5626
Mailing Address - Fax:847-746-2900
Practice Address - Street 1:644 SHERIDAN RD
Practice Address - Street 2:SUITE 105
Practice Address - City:WINTHROP HARBOR
Practice Address - State:IL
Practice Address - Zip Code:60096-1350
Practice Address - Country:US
Practice Address - Phone:847-872-5626
Practice Address - Fax:847-746-2900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190150261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILTRI-CAREOther603323
ILBCBS OF ILOther80006341
ILUNITED CONCORDIAOther603323