1427222520 NPI number — QUINTESSENTIAL DENTAL

Table of content: (NPI 1427222520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427222520 NPI number — QUINTESSENTIAL DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUINTESSENTIAL DENTAL
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:
HAPPY TOOTH
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:
1427222520
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 ADDISON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMHURST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-834-4141
Provider Business Mailing Address Fax Number:
630-834-4577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 N ADDISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELMHURST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-834-4140
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/18/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
AUGUSTYN
Authorized Official First Name:
MAGGIE
Authorized Official Middle Name:
W
Authorized Official Title or Position:
DENTIST/PRESIDENT
Authorized Official Telephone Number:
630-834-4140

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9185625 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9815623 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".