Provider Demographics
NPI:1942462080
Name:DEXTER DENTAL LLC
Entity Type:Organization
Organization Name:DEXTER DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING & PAYER RELATIONS MAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:847-453-7396
Mailing Address - Street 1:2050 EAST ALGONQUIN ROAD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4166
Mailing Address - Country:US
Mailing Address - Phone:847-453-7396
Mailing Address - Fax:847-453-7396
Practice Address - Street 1:47 CLOCK TOWER PLAZA
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-7800
Practice Address - Country:US
Practice Address - Phone:847-695-8780
Practice Address - Fax:847-695-0939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026920122300000X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No122300000XDental ProvidersDentistGroup - Single Specialty