Provider Demographics
NPI:1457657744
Name:LITCHFIELD DENTAL PROFESSIONALS
Entity Type:Organization
Organization Name:LITCHFIELD DENTAL PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:DARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-502-7339
Mailing Address - Street 1:1922 EDWARDSVILLE CLUB PLAZA
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025
Mailing Address - Country:US
Mailing Address - Phone:217-303-8787
Mailing Address - Fax:217-324-6194
Practice Address - Street 1:318 N. MADISON
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056
Practice Address - Country:US
Practice Address - Phone:217-303-8787
Practice Address - Fax:217-324-6194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-03
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190252811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty