Provider Demographics
NPI:1659921575
Name:OLYMPIA FIELDS FAMILY DENTAL
Entity Type:Organization
Organization Name:OLYMPIA FIELDS FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-339-3172
Mailing Address - Street 1:20180 GOVERNORS HWY STE 104
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1065
Mailing Address - Country:US
Mailing Address - Phone:708-747-9777
Mailing Address - Fax:
Practice Address - Street 1:20180 GOVERNORS HWY STE 104
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1065
Practice Address - Country:US
Practice Address - Phone:708-747-9777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental