Provider Demographics
NPI:1356617492
Name:A DENTAL PLACE LTD
Entity type:Organization
Organization Name:A DENTAL PLACE LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-620-7300
Mailing Address - Street 1:845 S MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-3350
Mailing Address - Country:US
Mailing Address - Phone:630-620-7300
Mailing Address - Fax:630-620-7352
Practice Address - Street 1:845 S MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-3350
Practice Address - Country:US
Practice Address - Phone:630-620-7300
Practice Address - Fax:630-620-7352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190208121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty