Provider Demographics
NPI:1649210352
Name:FHN MEMORIAL ENTERPRISES
Entity Type:Organization
Organization Name:FHN MEMORIAL ENTERPRISES
Other - Org Name:FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-235-2600
Mailing Address - Street 1:1768 S ROSENSTIEL DR
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032
Mailing Address - Country:US
Mailing Address - Phone:815-235-2600
Mailing Address - Fax:815-235-9846
Practice Address - Street 1:1768 S ROSENSTIEL DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032
Practice Address - Country:US
Practice Address - Phone:815-235-2600
Practice Address - Fax:815-235-9846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1005536Medicaid
IL9177538Medicaid
IL9178466Medicaid
IL1004800Medicaid