Provider Demographics
NPI:1942377908
Name:PERFORMANCE DENTAL CARE PC
Entity Type:Organization
Organization Name:PERFORMANCE DENTAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES OF CORP
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FATLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:815-464-8850
Mailing Address - Street 1:7230 191ST ST
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-9378
Mailing Address - Country:US
Mailing Address - Phone:815-464-8850
Mailing Address - Fax:708-777-4797
Practice Address - Street 1:7230 191ST ST
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-9378
Practice Address - Country:US
Practice Address - Phone:815-464-8850
Practice Address - Fax:708-777-4797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190250701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty