Provider Demographics
NPI:1467450783
Name:DRS. NELSON AND GARY DENTAL ASSOC. LTA
Entity Type:Organization
Organization Name:DRS. NELSON AND GARY DENTAL ASSOC. LTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER CORPORATE SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:842-895-4513
Mailing Address - Street 1:1443 W SCHAUMBURG RD
Mailing Address - Street 2:STE 102
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60194-4065
Mailing Address - Country:US
Mailing Address - Phone:847-895-4510
Mailing Address - Fax:847-895-8834
Practice Address - Street 1:1443 W SCHAUMBURG RD
Practice Address - Street 2:STE 102
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60194-4065
Practice Address - Country:US
Practice Address - Phone:847-895-4510
Practice Address - Fax:847-895-8834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QD0000X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental