Provider Demographics
NPI:1790262434
Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Other - Org Name:FOX LAKE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8426
Mailing Address - Street 1:1402 S US HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:FOX LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60020-1252
Mailing Address - Country:US
Mailing Address - Phone:847-973-6765
Mailing Address - Fax:847-973-6749
Practice Address - Street 1:1402 S US HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1252
Practice Address - Country:US
Practice Address - Phone:217-540-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-25
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty