Healthcare Provider Details

I. General information

NPI: 1295240836
Provider Name (Legal Business Name): ORTHODONTIC EXPERTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 S RANDALL RD
ALGONQUIN IL
60102-9774
US

IV. Provider business mailing address

272 S RANDALL RD
ALGONQUIN IL
60102-9775
US

V. Phone/Fax

Practice location:
  • Phone: 847-658-4907
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1154674471
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name: MONIKA BZDAL
Title or Position: MANAGER
Credential:
Phone: 773-801-7171