Provider Demographics
NPI:1750494142
Name:SCOTT P. FOGEL DDS PC
Entity Type:Organization
Organization Name:SCOTT P. FOGEL DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:P
Authorized Official - Last Name:FOGEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-933-5173
Mailing Address - Street 1:1521 N CONVENT ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1468
Mailing Address - Country:US
Mailing Address - Phone:815-933-5173
Mailing Address - Fax:815-933-5191
Practice Address - Street 1:1521 N CONVENT ST
Practice Address - Street 2:SUITE 600
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1468
Practice Address - Country:US
Practice Address - Phone:815-933-5173
Practice Address - Fax:815-933-5191
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCOTT P. FOGEL DDS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-17
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190263911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty