1124185467 NPI number — PROCARE DENTAL GROUP, P.C.

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 1124185467 NPI number — PROCARE DENTAL GROUP, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROCARE DENTAL GROUP, P.C.
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:
GRAND DENTISTRY
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:
1124185467
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
605 E ALGONQUIN RD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
ARLINGTON HEIGHTS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60005-4373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-640-1112
Provider Business Mailing Address Fax Number:
847-640-1107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5445 GRAND AVE
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
GURNEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60031-1725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-244-2775
Provider Business Practice Location Address Fax Number:
847-244-2777
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRUNETTI
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
847-640-1112

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)





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