Provider Demographics
NPI:1609995885
Name:LANARK DENTAL CLINIC, P.C.
Entity Type:Organization
Organization Name:LANARK DENTAL CLINIC, P.C.
Other - Org Name:LANARK DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-493-2244
Mailing Address - Street 1:120 S BROAD ST
Mailing Address - Street 2:P.O. BOX 43
Mailing Address - City:LANARK
Mailing Address - State:IL
Mailing Address - Zip Code:61046-1204
Mailing Address - Country:US
Mailing Address - Phone:815-493-2244
Mailing Address - Fax:815-493-2922
Practice Address - Street 1:120 S BROAD ST
Practice Address - Street 2:
Practice Address - City:LANARK
Practice Address - State:IL
Practice Address - Zip Code:61046-1204
Practice Address - Country:US
Practice Address - Phone:815-493-2244
Practice Address - Fax:815-493-2922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty