Provider Demographics
NPI:1790171023
Name:MEDCOA DENTAL CENTER PC
Entity Type:Organization
Organization Name:MEDCOA DENTAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EUN
Authorized Official - Middle Name:
Authorized Official - Last Name:SO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-843-1170
Mailing Address - Street 1:1000 GRAND CANYON PARKWAY #308
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-1705
Mailing Address - Country:US
Mailing Address - Phone:847-843-1170
Mailing Address - Fax:
Practice Address - Street 1:1000 GRAND CANYON PARKWAY #308
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-1705
Practice Address - Country:US
Practice Address - Phone:847-843-1170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190219471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019021947Medicaid
1619015062OtherINDIVIDUAL NPI NUMBER