Provider Demographics
NPI:1942754221
Name:IMAGE DENTISTRY
Entity Type:Organization
Organization Name:IMAGE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GAYLORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-804-5229
Mailing Address - Street 1:830 W STATE ROUTE 22 # 49
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-2560
Mailing Address - Country:US
Mailing Address - Phone:847-265-9022
Mailing Address - Fax:847-265-9023
Practice Address - Street 1:2450 GRASS LAKE RD
Practice Address - Street 2:SUITE C
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-5613
Practice Address - Country:US
Practice Address - Phone:847-265-9022
Practice Address - Fax:847-265-9023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190228641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty