Provider Demographics
NPI:1649378571
Name:HIDDEN LAKES DENTAL CARE, P.C.
Entity Type:Organization
Organization Name:HIDDEN LAKES DENTAL CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:CROWL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-759-0077
Mailing Address - Street 1:680 W BOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2185
Mailing Address - Country:US
Mailing Address - Phone:630-759-0077
Mailing Address - Fax:630-759-0082
Practice Address - Street 1:680 W BOUGHTON RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2185
Practice Address - Country:US
Practice Address - Phone:630-759-0077
Practice Address - Fax:630-759-0082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060-007659122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty