Provider Demographics
NPI:1710091673
Name:COLONIAL DENTAL GROUP
Entity Type:Organization
Organization Name:COLONIAL DENTAL GROUP
Other - Org Name:DR DAVID L DOOLEY DR DAVID B LEWIS DR ALEXANDER QUEZADA
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:QUEZADA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-729-2233
Mailing Address - Street 1:1775 GLENVIEW RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025
Mailing Address - Country:US
Mailing Address - Phone:847-729-2233
Mailing Address - Fax:847-729-6908
Practice Address - Street 1:1775 GLENVIEW RD
Practice Address - Street 2:SUITE 107
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025
Practice Address - Country:US
Practice Address - Phone:847-729-2233
Practice Address - Fax:847-729-6908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X, 1223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTIN