Provider Demographics
NPI:1568751436
Name:LONG GROVE DENTAL STUDIO
Entity Type:Organization
Organization Name:LONG GROVE DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DEMARS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-719-1973
Mailing Address - Street 1:3976 ROUTE 22
Mailing Address - Street 2:SUITE E
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047
Mailing Address - Country:US
Mailing Address - Phone:847-719-1973
Mailing Address - Fax:847-719-1975
Practice Address - Street 1:3976 ROUTE 22
Practice Address - Street 2:SUITE E
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047
Practice Address - Country:US
Practice Address - Phone:847-719-1973
Practice Address - Fax:847-719-1975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025986122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty