Provider Demographics
NPI:1023430360
Name:THE LOOSE TOOTH PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:THE LOOSE TOOTH PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RHIANNON
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:HOLCOMBE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:815-267-7299
Mailing Address - Street 1:15041 S VAN DYKE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-5805
Mailing Address - Country:US
Mailing Address - Phone:815-267-7299
Mailing Address - Fax:815-267-7511
Practice Address - Street 1:15041 S VAN DYKE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-5805
Practice Address - Country:US
Practice Address - Phone:815-267-7299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190272491223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty