1831713098 NPI number — OAK FAMILY DENTAL

Table of content: (NPI 1831713098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831713098 NPI number — OAK FAMILY DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAK FAMILY 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:
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:
1831713098
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6056 W. 159TH AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK FOREST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-925-0223
Provider Business Mailing Address Fax Number:
708-290-3302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6056 W. 159TH AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK FOREST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-925-0223
Provider Business Practice Location Address Fax Number:
708-290-3302
Provider Enumeration Date:
06/03/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCLEAN
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER.
Authorized Official Telephone Number:
815-260-3729

Provider Taxonomy Codes

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

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