Provider Demographics
NPI:1356719603
Name:LAKEMOOR DENTAL
Entity type:Organization
Organization Name:LAKEMOOR DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-363-8888
Mailing Address - Street 1:28956 W. RT 120
Mailing Address - Street 2:
Mailing Address - City:LAKEMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60051
Mailing Address - Country:US
Mailing Address - Phone:815-363-8888
Mailing Address - Fax:815-363-8890
Practice Address - Street 1:28956 W. RT 120
Practice Address - Street 2:
Practice Address - City:LAKEMOOR
Practice Address - State:IL
Practice Address - Zip Code:60051
Practice Address - Country:US
Practice Address - Phone:815-363-8888
Practice Address - Fax:815-363-8890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty