Provider Demographics
NPI:1972392751
Name:CRYSTAL COVE FAMILY DENTAL PLLC
Entity type:Organization
Organization Name:CRYSTAL COVE FAMILY DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FLORENTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMACHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-614-1111
Mailing Address - Street 1:15614 S HARLEM AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4401
Mailing Address - Country:US
Mailing Address - Phone:708-614-1111
Mailing Address - Fax:708-614-1117
Practice Address - Street 1:15614 S HARLEM AVE STE A
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4401
Practice Address - Country:US
Practice Address - Phone:708-614-1111
Practice Address - Fax:708-614-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty