Provider Demographics
NPI:1760633564
Name:KIDS PLUS PEDIATRIC DENTISTRY, PC
Entity Type:Organization
Organization Name:KIDS PLUS PEDIATRIC DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HEALY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-772-7373
Mailing Address - Street 1:990 GRAND CANYON PKWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-1739
Mailing Address - Country:US
Mailing Address - Phone:847-882-2555
Mailing Address - Fax:847-882-9260
Practice Address - Street 1:990 GRAND CANYON PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-1739
Practice Address - Country:US
Practice Address - Phone:847-882-2555
Practice Address - Fax:847-882-9260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190238921223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6016901Medicaid