Provider Demographics
NPI:1801948237
Name:BARWELL DENTAL CLINIC, INC.
Entity type:Organization
Organization Name:BARWELL DENTAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGOS
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MBA
Authorized Official - Phone:847-244-5608
Mailing Address - Street 1:201 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-6515
Mailing Address - Country:US
Mailing Address - Phone:847-244-5608
Mailing Address - Fax:
Practice Address - Street 1:201 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-6515
Practice Address - Country:US
Practice Address - Phone:847-244-5608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101325OtherPAYEE ID NUMBER
IL9175784Medicaid