Provider Demographics
NPI:1396185633
Name:AL WEATHERFORD DDS INC
Entity Type:Organization
Organization Name:AL WEATHERFORD DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WEATHERFORD
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-932-3616
Mailing Address - Street 1:200 E COURT ST
Mailing Address - Street 2:SUITE 504
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3843
Mailing Address - Country:US
Mailing Address - Phone:815-932-3613
Mailing Address - Fax:
Practice Address - Street 1:200 E COURT ST
Practice Address - Street 2:SUITE 504
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3843
Practice Address - Country:US
Practice Address - Phone:815-932-3613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBW59331531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty