Provider Demographics
NPI:1477724870
Name:DENTAL PROFILE 2
Entity Type:Organization
Organization Name:DENTAL PROFILE 2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MILAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RONCEVIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-516-0000
Mailing Address - Street 1:120 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-2821
Mailing Address - Country:US
Mailing Address - Phone:630-530-2498
Mailing Address - Fax:630-530-2689
Practice Address - Street 1:120 E LAKE ST
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2821
Practice Address - Country:US
Practice Address - Phone:630-530-2498
Practice Address - Fax:630-530-2689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty