Provider Demographics
NPI:1659442788
Name:WHEATON FAMILY DENTISTRY, PC
Entity Type:Organization
Organization Name:WHEATON FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BOEHM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-681-1280
Mailing Address - Street 1:67 DANADA SQ E
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-8484
Mailing Address - Country:US
Mailing Address - Phone:630-681-1280
Mailing Address - Fax:630-681-1380
Practice Address - Street 1:67 DANADA SQ E
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-8484
Practice Address - Country:US
Practice Address - Phone:630-681-1280
Practice Address - Fax:630-681-1380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty