Provider Demographics
NPI:1518380070
Name:COTTAGE DENTAL CARE LLC
Entity Type:Organization
Organization Name:COTTAGE DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:KRUG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-828-1463
Mailing Address - Street 1:2206 COTTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1447
Mailing Address - Country:US
Mailing Address - Phone:309-828-1463
Mailing Address - Fax:
Practice Address - Street 1:2206 COTTAGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-1447
Practice Address - Country:US
Practice Address - Phone:309-828-1463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0187091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty