1376765818 NPI number — DENTAL PROFESSIONALS OF ILLINOIS, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376765818 NPI number — DENTAL PROFESSIONALS OF ILLINOIS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL PROFESSIONALS OF ILLINOIS, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NORTHGATE FAMILY DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376765818
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3412 W WILLOW KNOLLS ROAD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-690-3262
Provider Business Mailing Address Fax Number:
309-693-8295

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3412 W WILLOW KNOLLS ROAD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-690-3262
Provider Business Practice Location Address Fax Number:
309-693-8295
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BEARDEN
Authorized Official First Name:
LINDSAY
Authorized Official Middle Name:
Authorized Official Title or Position:
INS COOD
Authorized Official Telephone Number:
217-540-5100

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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