Provider Demographics
NPI:1013462175
Name:5 STAR FAMILY DENTAL
Entity type:Organization
Organization Name:5 STAR FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:FATLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:708-990-7869
Mailing Address - Street 1:615 E 162ND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2329
Mailing Address - Country:US
Mailing Address - Phone:708-331-1900
Mailing Address - Fax:
Practice Address - Street 1:615 E 162ND ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2329
Practice Address - Country:US
Practice Address - Phone:708-331-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190250701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty