Provider Demographics
NPI:1669548830
Name:DENTAL OFFICE 300 MEMORIAL DRIVE LLC
Entity type:Organization
Organization Name:DENTAL OFFICE 300 MEMORIAL DRIVE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCNERNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-459-8127
Mailing Address - Street 1:300 MEMORIAL DR STE 400
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6273
Mailing Address - Country:US
Mailing Address - Phone:815-459-8127
Mailing Address - Fax:815-459-8427
Practice Address - Street 1:300 MEMORIAL DR STE 400
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6273
Practice Address - Country:US
Practice Address - Phone:815-459-8127
Practice Address - Fax:815-459-8427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty