Provider Demographics
NPI:1902412158
Name:LAVENDER ROSE DENTAL
Entity Type:Organization
Organization Name:LAVENDER ROSE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SHIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHOENIX
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:575-840-4838
Mailing Address - Street 1:333 N MOREHEAD ST
Mailing Address - Street 2:
Mailing Address - City:CHENOA
Mailing Address - State:IL
Mailing Address - Zip Code:61726-1001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 N MOREHEAD ST
Practice Address - Street 2:
Practice Address - City:CHENOA
Practice Address - State:IL
Practice Address - Zip Code:61726-1001
Practice Address - Country:US
Practice Address - Phone:815-945-7808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental