Provider Demographics
NPI:1518964402
Name:ROSELLE DENTAL CENTER PC
Entity Type:Organization
Organization Name:ROSELLE DENTAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:SEYBOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-893-4200
Mailing Address - Street 1:603 E IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-2302
Mailing Address - Country:US
Mailing Address - Phone:630-893-4200
Mailing Address - Fax:630-893-4508
Practice Address - Street 1:603 E IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172-2302
Practice Address - Country:US
Practice Address - Phone:630-893-4200
Practice Address - Fax:630-893-4508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019017668122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty