Provider Demographics
NPI:1508946815
Name:AFO DENTAL GROUP
Entity Type:Organization
Organization Name:AFO DENTAL GROUP
Other - Org Name:AUGUSTA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-247-0600
Mailing Address - Street 1:1424 S BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-9424
Mailing Address - Country:US
Mailing Address - Phone:847-247-0600
Mailing Address - Fax:
Practice Address - Street 1:1424 S BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-9424
Practice Address - Country:US
Practice Address - Phone:847-247-0600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty