Provider Demographics
NPI:1750747978
Name:CRYSTAL FAMILY DENTAL
Entity type:Organization
Organization Name:CRYSTAL FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:N
Authorized Official - Last Name:HARVALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-439-1270
Mailing Address - Street 1:2405 ESSINGTON RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-1200
Mailing Address - Country:US
Mailing Address - Phone:815-439-1270
Mailing Address - Fax:815-439-3508
Practice Address - Street 1:2405 ESSINGTON RD
Practice Address - Street 2:SUITE D
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1200
Practice Address - Country:US
Practice Address - Phone:815-439-1270
Practice Address - Fax:815-439-3508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190276161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty