1013980705 NPI number — ILLINOIS DENTAL PROVIDERS (HARLEM & NORTH), LTD.

Table of content: (NPI 1013980705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013980705 NPI number — ILLINOIS DENTAL PROVIDERS (HARLEM & NORTH), LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS DENTAL PROVIDERS (HARLEM & NORTH), LTD.
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:
DENTALWORKS OF FOREST PARK
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:
1013980705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7160 DALLAS PKWY STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75024-7111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-755-0816
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7235 MADISON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60130-1764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-405-9344
Provider Business Practice Location Address Fax Number:
216-584-1016
Provider Enumeration Date:
02/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NITTINGER
Authorized Official First Name:
RACHEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER CREDENTIALING
Authorized Official Telephone Number:
972-755-0816

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223E0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 019.022557 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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