1578668737 NPI number — BLOOMINGDALE FAMILY DENTAL LTD

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 1578668737 NPI number — BLOOMINGDALE FAMILY DENTAL LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOOMINGDALE FAMILY DENTAL LTD
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:
1578668737
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:
135 FIRST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-893-4650
Provider Business Mailing Address Fax Number:
630-894-9515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
135 FIRST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-893-4650
Provider Business Practice Location Address Fax Number:
630-894-9515
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ECO
Authorized Official First Name:
JASMIN
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
630-893-4650

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)





Copyright © 2007-2026 www.npivalidator.com