Provider Demographics
NPI:1982186896
Name:SOUTHWEST FAMILY DENTAL
Entity Type:Organization
Organization Name:SOUTHWEST FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCGRAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-485-3449
Mailing Address - Street 1:165 S MARLEY RD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-3302
Mailing Address - Country:US
Mailing Address - Phone:815-485-3449
Mailing Address - Fax:
Practice Address - Street 1:165 S MARLEY RD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-6045
Practice Address - Country:US
Practice Address - Phone:815-485-3449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029805261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental