Provider Demographics
NPI:1437881224
Name:FLANNAGAN-DA DENTAL, LLC
Entity Type:Organization
Organization Name:FLANNAGAN-DA DENTAL, LLC
Other - Org Name:LASTING IMPRESSIONS DENTAL LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VILK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-463-4110
Mailing Address - Street 1:522 E JASPER ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:IL
Mailing Address - Zip Code:61944-2437
Mailing Address - Country:US
Mailing Address - Phone:217-348-7770
Mailing Address - Fax:
Practice Address - Street 1:14649 N GRAY RD
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46062-9274
Practice Address - Country:US
Practice Address - Phone:317-571-9610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental