Provider Demographics
NPI:1710387162
Name:MARK E KLEIN DDS AND ASSOCIATES PC
Entity Type:Organization
Organization Name:MARK E KLEIN DDS AND ASSOCIATES PC
Other - Org Name:VILLAGE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-364-5100
Mailing Address - Street 1:958 ELK GROVE TOWN CTR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3754
Mailing Address - Country:US
Mailing Address - Phone:847-364-5100
Mailing Address - Fax:847-364-9807
Practice Address - Street 1:958 ELK GROVE TOWN CTR
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3754
Practice Address - Country:US
Practice Address - Phone:847-364-5100
Practice Address - Fax:847-364-9807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190174671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty