Provider Demographics
NPI:1376605428
Name:CCB DENTAL ASSOCIATES PC
Entity Type:Organization
Organization Name:CCB DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CHRISTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-729-0661
Mailing Address - Street 1:1118 N LARKIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435
Mailing Address - Country:US
Mailing Address - Phone:815-729-0661
Mailing Address - Fax:815-729-1617
Practice Address - Street 1:1118 N LARKIN AVENUE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435
Practice Address - Country:US
Practice Address - Phone:815-729-0661
Practice Address - Fax:815-729-1617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X, 122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========Medicare UPIN