Provider Demographics
NPI:1437403029
Name:FARMINGTON LAKES DENTAL
Entity Type:Organization
Organization Name:FARMINGTON LAKES DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KABIL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUNPRAPAPH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:331-212-5085
Mailing Address - Street 1:1241 FARMINGTON LAKES DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-5109
Mailing Address - Country:US
Mailing Address - Phone:331-212-5085
Mailing Address - Fax:
Practice Address - Street 1:1241 FARMINGTON LAKES DR
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-5109
Practice Address - Country:US
Practice Address - Phone:331-212-5085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-03
Last Update Date:2012-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025947261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental