Provider Demographics
NPI:1437355013
Name:STEPHEN P MORIMOTO, DDS, LTD
Entity Type:Organization
Organization Name:STEPHEN P MORIMOTO, DDS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MORIMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-741-0095
Mailing Address - Street 1:219 N HAMMES AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-8114
Mailing Address - Country:US
Mailing Address - Phone:815-741-0095
Mailing Address - Fax:815-741-0328
Practice Address - Street 1:219 N HAMMES AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8114
Practice Address - Country:US
Practice Address - Phone:815-741-0095
Practice Address - Fax:815-741-0328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL80006668OtherBLUE CROSS BLUE SHIELD
IL80006668OtherBLUE CROSS BLUE SHIELD
IL683030Medicare PIN