Provider Demographics
NPI:1427222520
Name:QUINTESSENTIAL DENTAL
Entity Type:Organization
Organization Name:QUINTESSENTIAL DENTAL
Other - Org Name:HAPPY TOOTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAGGIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:AUGUSTYN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-834-4140
Mailing Address - Street 1:130 ADDISON AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126
Mailing Address - Country:US
Mailing Address - Phone:630-834-4141
Mailing Address - Fax:630-834-4577
Practice Address - Street 1:130 N ADDISON AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126
Practice Address - Country:US
Practice Address - Phone:630-834-4140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9185625Medicaid
IL9815623Medicaid