Provider Demographics
NPI:1295978104
Name:SUBURBAN FAMILY DENTAL
Entity type:Organization
Organization Name:SUBURBAN FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-640-0778
Mailing Address - Street 1:645 WEST GOLF ROAD
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016
Mailing Address - Country:US
Mailing Address - Phone:847-640-0778
Mailing Address - Fax:847-640-2599
Practice Address - Street 1:645 W GOLF RD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-2462
Practice Address - Country:US
Practice Address - Phone:847-640-0778
Practice Address - Fax:847-640-2599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190225141223G0001X
IL0190163621223G0001X
IL0190224851223P0300X
IL0190168341223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty