Provider Demographics
NPI:1972848935
Name:SUGAR GROVE DENTAL ASSOCIATES,PC
Entity Type:Organization
Organization Name:SUGAR GROVE DENTAL ASSOCIATES,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:DEWEIRDT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-466-1100
Mailing Address - Street 1:495 N STATE ROUTE 47
Mailing Address - Street 2:SUITE J
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-8009
Mailing Address - Country:US
Mailing Address - Phone:630-466-1100
Mailing Address - Fax:630-466-7933
Practice Address - Street 1:495 N STATE ROUTE 47
Practice Address - Street 2:SUITE J
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554-8009
Practice Address - Country:US
Practice Address - Phone:630-466-1100
Practice Address - Fax:630-466-7933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-019321261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental