Provider Demographics
NPI:1669924833
Name:LLCDENTAL,
Entity type:Organization
Organization Name:LLCDENTAL,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:MIMMS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:708-747-2273
Mailing Address - Street 1:3494 VOLLMER RD
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1018
Mailing Address - Country:US
Mailing Address - Phone:708-747-2273
Mailing Address - Fax:708-747-2238
Practice Address - Street 1:3494 VOLLMER RD
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1018
Practice Address - Country:US
Practice Address - Phone:708-747-2273
Practice Address - Fax:708-747-2238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020348122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty