Provider Demographics
NPI:1013336445
Name:HERITAGE GROVE FAMILY DENTAL P.C.
Entity Type:Organization
Organization Name:HERITAGE GROVE FAMILY DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GALLOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-254-1375
Mailing Address - Street 1:12426 S VAN DYKE RD
Mailing Address - Street 2:UNIT B
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-2700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12426 S VAN DYKE RD
Practice Address - Street 2:UNIT B
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-2700
Practice Address - Country:US
Practice Address - Phone:815-254-1375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190255011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty