Provider Demographics
NPI:1457817983
Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C
Other - Org Name:REDWING DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-788-7348
Mailing Address - Street 1:421 E IL ROUTE 173
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-9406
Mailing Address - Country:US
Mailing Address - Phone:847-929-9736
Mailing Address - Fax:
Practice Address - Street 1:421 E IL ROUTE 173
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-9406
Practice Address - Country:US
Practice Address - Phone:847-929-9736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-20
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty