Provider Demographics
NPI:1346651577
Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Other - Org Name:OSWEGO COMMONS FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAYL
Authorized Official - Middle Name:
Authorized Official - Last Name:BEARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:1490 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-5106
Mailing Address - Country:US
Mailing Address - Phone:331-725-7669
Mailing Address - Fax:
Practice Address - Street 1:1490 DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-5106
Practice Address - Country:US
Practice Address - Phone:331-725-7669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty