Provider Demographics
NPI:1922309400
Name:PARKSIDE DENTAL, LLC
Entity Type:Organization
Organization Name:PARKSIDE DENTAL, LLC
Other - Org Name:RICHARD H. MCKONE DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:HUGH
Authorized Official - Last Name:MCKONE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-693-0043
Mailing Address - Street 1:1645 S. RIVER RD.
Mailing Address - Street 2:SUITE 21
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018
Mailing Address - Country:US
Mailing Address - Phone:847-299-4811
Mailing Address - Fax:847-299-4379
Practice Address - Street 1:1645 S. RIVER RD.
Practice Address - Street 2:SUITE 21
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018
Practice Address - Country:US
Practice Address - Phone:847-299-4811
Practice Address - Fax:847-299-4379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0225501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty