1548535040 NPI number — RIVER POINTE DENTAL OF HUNTLEY

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 1548535040 NPI number — RIVER POINTE DENTAL OF HUNTLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVER POINTE DENTAL OF HUNTLEY
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:
Provider Other Organization Name Type Code:
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:
1548535040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12080 PRINCETON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTLEY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60142-7654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-515-8600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12080 PRINCETON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTLEY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60142-7654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-515-8600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HARDY
Authorized Official First Name:
RACHELLE
Authorized Official Middle Name:
DYANE
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
847-515-8600

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  19025215 , 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)





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