Provider Demographics
NPI:1265426217
Name:DENNIS DETTMANN, O.D. S.C.
Entity type:Organization
Organization Name:DENNIS DETTMANN, O.D. S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:DETTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:630-257-6493
Mailing Address - Street 1:21219 SILKTREE CIR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-9359
Mailing Address - Country:US
Mailing Address - Phone:630-257-6493
Mailing Address - Fax:630-243-6293
Practice Address - Street 1:21219 SILKTREE CIR
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-9359
Practice Address - Country:US
Practice Address - Phone:630-257-6493
Practice Address - Fax:630-243-6293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007054152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007054Medicaid
IL=========TOtherBC/BS MEDICARE CROSSOVER
IL046007054Medicaid
ILK08127Medicare PIN
IL209322Medicare PIN
IL0531040001Medicare NSC
IL410040714Medicare PIN
IL209240Medicare PIN
IL=========TOtherBC/BS MEDICARE CROSSOVER
IL410040713Medicare PIN
ILT39192Medicare UPIN
IL215338Medicare PIN