Provider Demographics
NPI:1346433000
Name:PRAIRIE VALLEY DENTAL, P.C.
Entity Type:Organization
Organization Name:PRAIRIE VALLEY DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-365-1675
Mailing Address - Street 1:108 VALLEY DR UNIT H
Mailing Address - Street 2:
Mailing Address - City:ELBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60119-8872
Mailing Address - Country:US
Mailing Address - Phone:630-365-1675
Mailing Address - Fax:630-365-1678
Practice Address - Street 1:108 VALLEY DR UNIT H
Practice Address - Street 2:
Practice Address - City:ELBURN
Practice Address - State:IL
Practice Address - Zip Code:60119-8872
Practice Address - Country:US
Practice Address - Phone:630-365-1675
Practice Address - Fax:630-365-1678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental