Provider Demographics
NPI:1952502221
Name:DENTAL BOUTIQUE
Entity Type:Organization
Organization Name:DENTAL BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:815-806-1451
Mailing Address - Street 1:20646 ABBEY WOODS COURT NORTH
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-3169
Mailing Address - Country:US
Mailing Address - Phone:815-806-1451
Mailing Address - Fax:815-806-1454
Practice Address - Street 1:20646 ABBEY WOODS COURT NORTH
Practice Address - Street 2:SUITE 101
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-3169
Practice Address - Country:US
Practice Address - Phone:815-806-1451
Practice Address - Fax:815-806-1454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty