Provider Demographics
NPI:1497983688
Name:CHILDREN'S DENTISTRY GROUP, LLC
Entity Type:Organization
Organization Name:CHILDREN'S DENTISTRY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:DANA
Authorized Official - Last Name:HERER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:847-726-0300
Mailing Address - Street 1:195 S RAND RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-2205
Mailing Address - Country:US
Mailing Address - Phone:847-726-0300
Mailing Address - Fax:847-726-3799
Practice Address - Street 1:195 S RAND RD
Practice Address - Street 2:SUITE 110
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2205
Practice Address - Country:US
Practice Address - Phone:847-726-0300
Practice Address - Fax:847-726-3799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190148681223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty