Provider Demographics
NPI:1134628597
Name:ORLAND SQUARE DENTAL LLC
Entity type:Organization
Organization Name:ORLAND SQUARE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-869-5857
Mailing Address - Street 1:62 ORLAND SQUARE DR STE 304
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-6560
Mailing Address - Country:US
Mailing Address - Phone:708-349-1919
Mailing Address - Fax:
Practice Address - Street 1:62 ORLAND SQUARE DR STE 304
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-6560
Practice Address - Country:US
Practice Address - Phone:708-349-1919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019018843261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental