Provider Demographics
NPI:1952454878
Name:PEDIATRIC DENTISTRY LTD
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:NICKELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-695-1693
Mailing Address - Street 1:860 SUMMIT ST
Mailing Address - Street 2:SUITE 246
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-5145
Mailing Address - Country:US
Mailing Address - Phone:847-695-1693
Mailing Address - Fax:847-695-9212
Practice Address - Street 1:860 SUMMIT ST
Practice Address - Street 2:SUITE 246
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-5145
Practice Address - Country:US
Practice Address - Phone:847-695-1693
Practice Address - Fax:847-695-9212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental