Provider Demographics
NPI:1508935305
Name:DENTAL PROFESSIONALS OF ALGONQUIN, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF ALGONQUIN, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:AN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-458-6684
Mailing Address - Street 1:1485 MERCHANT DR
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-5917
Mailing Address - Country:US
Mailing Address - Phone:847-458-6684
Mailing Address - Fax:847-458-6683
Practice Address - Street 1:1485 MERCHANT DR
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-5917
Practice Address - Country:US
Practice Address - Phone:847-458-6684
Practice Address - Fax:847-458-6683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190254781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty