Provider Demographics
NPI:1972717247
Name:CANDACE M OPON DDS
Entity Type:Organization
Organization Name:CANDACE M OPON DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:M
Authorized Official - Last Name:OPON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-477-2177
Mailing Address - Street 1:690 N ROUTE 31
Mailing Address - Street 2:COLLEGE HILL PROFESSIONAL BLDG
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012
Mailing Address - Country:US
Mailing Address - Phone:815-477-2177
Mailing Address - Fax:815-477-8671
Practice Address - Street 1:690 N ROUTE 31
Practice Address - Street 2:COLLEGE HILL PROFESSIONAL BLDG
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012
Practice Address - Country:US
Practice Address - Phone:815-477-2177
Practice Address - Fax:815-477-8671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023866122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty