Provider Demographics
NPI:1740024066
Name:ENABLE DENTAL OF ILLINOIS PLLC
Entity type:Organization
Organization Name:ENABLE DENTAL OF ILLINOIS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:737-787-2049
Mailing Address - Street 1:5555 N LAMAR BLVD STE H125
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-1096
Mailing Address - Country:US
Mailing Address - Phone:866-988-4504
Mailing Address - Fax:866-815-3719
Practice Address - Street 1:5555 N LAMAR BLVD STE H125
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-1096
Practice Address - Country:US
Practice Address - Phone:866-988-4504
Practice Address - Fax:866-815-3719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental