Provider Demographics
NPI:1669645958
Name:ASHLEY FAMILY DENTAL, LTD.
Entity Type:Organization
Organization Name:ASHLEY FAMILY DENTAL, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOO
Authorized Official - Middle Name:H
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-244-0414
Mailing Address - Street 1:2504 WASHINGTON ST
Mailing Address - Street 2:STE #503
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-4983
Mailing Address - Country:US
Mailing Address - Phone:847-244-0414
Mailing Address - Fax:847-244-3104
Practice Address - Street 1:2504 WASHINGTON ST
Practice Address - Street 2:STE #503
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-4983
Practice Address - Country:US
Practice Address - Phone:847-244-0414
Practice Address - Fax:847-244-3104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL182486Medicaid