1285144493 NPI number — DENTAL PARTNERS OF WOODRIDGE LLC

Table of content: (NPI 1285144493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285144493 NPI number — DENTAL PARTNERS OF WOODRIDGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL PARTNERS OF WOODRIDGE LLC
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:
1285144493
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2309 63RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODRIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60517-1300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-869-0063
Provider Business Mailing Address Fax Number:
630-296-8966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2309 63RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODRIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60517-1300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-869-0063
Provider Business Practice Location Address Fax Number:
630-296-8966
Provider Enumeration Date:
10/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BLASKO
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST/PARTNER
Authorized Official Telephone Number:
630-869-0063

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  019.026417 , 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)





Copyright © 2007-2025 www.npivalidator.com