Healthcare Provider Details

I. General information

NPI: 1922375450
Provider Name (Legal Business Name): SCHMIDT/FAITH ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2011
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E ALGONQUIN RD STE 216
ALGONQUIN IL
60102-9632
US

IV. Provider business mailing address

1700 E ALGONQUIN RD
ALGONQUIN IL
60102-9632
US

V. Phone/Fax

Practice location:
  • Phone: 847-854-1873
  • Fax: 847-854-3975
Mailing address:
  • Phone: 847-854-1873
  • Fax: 847-854-3975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number248000457
License Number StateIL

VIII. Authorized Official

Name: MRS. DEANNE M SCHMIDT
Title or Position: PRESIDENT
Credential:
Phone: 847-854-1873