Provider Demographics
NPI:1336505171
Name:ELK GROVE DENTAL, LLC
Entity Type:Organization
Organization Name:ELK GROVE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF
Authorized Official - Prefix:
Authorized Official - First Name:A.
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-895-0000
Mailing Address - Street 1:1121 NERGE RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3260
Mailing Address - Country:US
Mailing Address - Phone:847-895-0000
Mailing Address - Fax:
Practice Address - Street 1:1121 NERGE RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3260
Practice Address - Country:US
Practice Address - Phone:847-895-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-09
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.025459122300000X
IL019.024689122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty