Provider Demographics
NPI:1811062557
Name:DYNAMIC DENTAL GROUP, P.C.
Entity type:Organization
Organization Name:DYNAMIC DENTAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:K
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-283-4900
Mailing Address - Street 1:2102 W RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1973
Mailing Address - Country:US
Mailing Address - Phone:618-283-4900
Mailing Address - Fax:618-283-4963
Practice Address - Street 1:2102 W RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1973
Practice Address - Country:US
Practice Address - Phone:618-283-4900
Practice Address - Fax:618-283-4963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0600038461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty