Provider Demographics
NPI:1790182327
Name:FLOSS DENTAL CARE LLC
Entity Type:Organization
Organization Name:FLOSS DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ACIERNO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-339-3172
Mailing Address - Street 1:18650 DIXIE HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18650 DIXIE HIGHWAY
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430
Practice Address - Country:US
Practice Address - Phone:630-339-3172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-25
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021636305R00000X
IL019028140305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019021636OtherPPO