Provider Demographics
NPI:1992003933
Name:AUSTIN DENTAL CENTER LLC
Entity Type:Organization
Organization Name:AUSTIN DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-386-1448
Mailing Address - Street 1:418 N AUSTIN BLVD
Mailing Address - Street 2:2B
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2752
Mailing Address - Country:US
Mailing Address - Phone:708-386-1448
Mailing Address - Fax:708-386-8943
Practice Address - Street 1:418 N AUSTIN BLVD
Practice Address - Street 2:2B
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2752
Practice Address - Country:US
Practice Address - Phone:708-386-1448
Practice Address - Fax:708-386-8943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-28
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX019012524122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty