Healthcare Provider Details

I. General information

NPI: 1669839593
Provider Name (Legal Business Name): ALGONQUIN KIDS DENTISTRY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2016
Last Update Date: 04/02/2022
Certification Date: 04/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4097 W ALGONQUIN RD
ALGONQUIN IL
60102-9401
US

IV. Provider business mailing address

4097 W ALGONQUIN RD
ALGONQUIN IL
60102-9401
US

V. Phone/Fax

Practice location:
  • Phone: 224-654-6543
  • Fax:
Mailing address:
  • Phone: 224-654-6543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number021.001777
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. VICTORIA URSITTI
Title or Position: OWNER/DOCTOR
Credential: D.M.D.
Phone: 224-654-6543