Provider Demographics
NPI:1811107998
Name:GLEN ELLYN ORTHODONTIC ASSOCIATES, P.C.
Entity type:Organization
Organization Name:GLEN ELLYN ORTHODONTIC ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS,PC
Authorized Official - Phone:630-469-5225
Mailing Address - Street 1:507 DUANE ST
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4549
Mailing Address - Country:US
Mailing Address - Phone:630-469-5225
Mailing Address - Fax:630-469-5443
Practice Address - Street 1:507 DUANE ST
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4549
Practice Address - Country:US
Practice Address - Phone:630-469-5225
Practice Address - Fax:630-469-5443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0142351223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty