Provider Demographics
NPI:1386016731
Name:SUBURBAN DENTAL SLEEP MEDICINE LLC
Entity Type:Organization
Organization Name:SUBURBAN DENTAL SLEEP MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUBINA
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-854-0525
Mailing Address - Street 1:500 N MCLEAN BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-3275
Mailing Address - Country:US
Mailing Address - Phone:847-854-3031
Mailing Address - Fax:224-227-6906
Practice Address - Street 1:500 N MCLEAN BLVD STE 102
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-3275
Practice Address - Country:US
Practice Address - Phone:847-854-3031
Practice Address - Fax:224-227-6906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.025559122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7467830001Medicare NSC