Provider Demographics
NPI:1609136373
Name:SCM DENTAL PC
Entity Type:Organization
Organization Name:SCM DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SONAL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-725-0260
Mailing Address - Street 1:2400 GLENWOOD AVE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5474
Mailing Address - Country:US
Mailing Address - Phone:815-725-0260
Mailing Address - Fax:815-729-2126
Practice Address - Street 1:2435 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5461
Practice Address - Country:US
Practice Address - Phone:815-725-0260
Practice Address - Fax:815-729-2126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-29
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190277261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL421529687Medicaid