Provider Demographics
NPI:1629658737
Name:DES PLAINES FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:DES PLAINES FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MYKOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-255-5050
Mailing Address - Street 1:1695 ELK BLVD
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-4721
Mailing Address - Country:US
Mailing Address - Phone:773-966-0505
Mailing Address - Fax:773-966-0510
Practice Address - Street 1:1695 ELK BLVD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4721
Practice Address - Country:US
Practice Address - Phone:773-966-0505
Practice Address - Fax:773-966-0510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental