Provider Demographics
NPI:1851971642
Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF ILLINOIS, P.C
Other - Org Name:INNOVATIVE DENTAL CARE OF SHOREWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUERTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:1526 IL ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-8215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1526 IL ROUTE 59
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-8215
Practice Address - Country:US
Practice Address - Phone:815-436-8787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty