1871826438 NPI number — ELMHURST DENTAL GROUP, LTD DBA BLOOMINGDALE DENTAL

Table of content: (NPI 1871826438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871826438 NPI number — ELMHURST DENTAL GROUP, LTD DBA BLOOMINGDALE DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELMHURST DENTAL GROUP, LTD DBA BLOOMINGDALE 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:
6
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:
1871826438
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 W 1ST ST
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:
60126-2641
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-833-5110
Provider Business Mailing Address Fax Number:
630-833-0458

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
290 SPRINGFIELD DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BLOOMINGDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60108-2214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-529-0027
Provider Business Practice Location Address Fax Number:
630-529-0068
Provider Enumeration Date:
09/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GROH
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
630-833-5110

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; 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: "Y" .

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





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