Provider Demographics
NPI:1134376189
Name:WESTLAKE DENTAL CENTER
Entity type:Organization
Organization Name:WESTLAKE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-587-3020
Mailing Address - Street 1:214 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:INGLESIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60041-9208
Mailing Address - Country:US
Mailing Address - Phone:847-587-3020
Mailing Address - Fax:847-587-1598
Practice Address - Street 1:214 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INGLESIDE
Practice Address - State:IL
Practice Address - Zip Code:60041-9208
Practice Address - Country:US
Practice Address - Phone:847-587-3020
Practice Address - Fax:847-587-1598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190269001223G0001X
IL0190253261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty