Provider Demographics
NPI:1073845400
Name:PROGRESSIVE DENTAL PC
Entity type:Organization
Organization Name:PROGRESSIVE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMULSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-385-9620
Mailing Address - Street 1:1301 PYOTT RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-9794
Mailing Address - Country:US
Mailing Address - Phone:847-458-7700
Mailing Address - Fax:
Practice Address - Street 1:1301 PYOTT RD
Practice Address - Street 2:SUITE 209
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156-9794
Practice Address - Country:US
Practice Address - Phone:847-458-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental