Provider Demographics
NPI:1720623325
Name:MAIN STREET SQUARE DENTAL, LLC
Entity Type:Organization
Organization Name:MAIN STREET SQUARE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-624-6700
Mailing Address - Street 1:1644 BARKEI DR
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-8304
Mailing Address - Country:US
Mailing Address - Phone:847-624-6700
Mailing Address - Fax:
Practice Address - Street 1:2932 FINLEY RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1042
Practice Address - Country:US
Practice Address - Phone:630-629-6299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty