Provider Demographics
NPI:1891028452
Name:ELMHURST DENTAL GROUP, LTD. DBA ST. CHARLES DENTAL
Entity Type:Organization
Organization Name:ELMHURST DENTAL GROUP, LTD. DBA ST. CHARLES DENTAL
Other - Org Name:ST. CHARLES DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:P
Authorized Official - Last Name:GROH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-833-5110
Mailing Address - Street 1:333 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2641
Mailing Address - Country:US
Mailing Address - Phone:630-833-5110
Mailing Address - Fax:630-833-0458
Practice Address - Street 1:2455 DEAN ST
Practice Address - Street 2:UNIT E
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-4830
Practice Address - Country:US
Practice Address - Phone:630-377-7760
Practice Address - Fax:630-377-7785
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELMHURST DENTAL GROUP, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty