Provider Demographics
NPI:1013077718
Name:METRO DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:METRO DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:PETROSELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-653-7890
Mailing Address - Street 1:640 E. SAINT CHARLES RD.
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-2600
Mailing Address - Country:US
Mailing Address - Phone:630-653-7890
Mailing Address - Fax:630-653-2394
Practice Address - Street 1:640 E. SAINT CHARLES RD.
Practice Address - Street 2:SUITE 204
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2600
Practice Address - Country:US
Practice Address - Phone:630-653-7890
Practice Address - Fax:630-653-2394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
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