Provider Demographics
NPI:1609053206
Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Other - Org Name:NORTH AURORA LIFETIME DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5699
Mailing Address - Street 1:100 HANSEN BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60542-8985
Mailing Address - Country:US
Mailing Address - Phone:630-896-3939
Mailing Address - Fax:630-896-3997
Practice Address - Street 1:100 HANSEN BLVD
Practice Address - Street 2:
Practice Address - City:NORTH AURORA
Practice Address - State:IL
Practice Address - Zip Code:60542-8985
Practice Address - Country:US
Practice Address - Phone:630-896-3939
Practice Address - Fax:630-896-3997
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-25
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty