Provider Demographics
NPI:1710196191
Name:RIDGE DENTAL GROUP, LTD
Entity Type:Organization
Organization Name:RIDGE DENTAL GROUP, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:FAITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-521-4292
Mailing Address - Street 1:2003 RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447
Mailing Address - Country:US
Mailing Address - Phone:815-521-4292
Mailing Address - Fax:
Practice Address - Street 1:2003 RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:MINOOKA
Practice Address - State:IL
Practice Address - Zip Code:60447
Practice Address - Country:US
Practice Address - Phone:815-521-4292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190245221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty