Healthcare Provider Details

I. General information

NPI: 1598347403
Provider Name (Legal Business Name): TRU DENTAL ILLINOIS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 DIXIE HWY
BEECHER IL
60401-3698
US

IV. Provider business mailing address

526 DIXIE HWY
BEECHER IL
60401-3698
US

V. Phone/Fax

Practice location:
  • Phone: 708-946-9494
  • Fax: 708-946-9494
Mailing address:
  • Phone: 708-946-9494
  • Fax: 708-946-9494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CELIA HAYES
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-2100