Healthcare Provider Details

I. General information

NPI: 1285985549
Provider Name (Legal Business Name): STRATFORD DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 SPRINGFIELD DR SUITE #130
BLOOMINGDALE IL
60108-2214
US

IV. Provider business mailing address

290 SPRINGFIELD DR SUITE #130
BLOOMINGDALE IL
60108-2214
US

V. Phone/Fax

Practice location:
  • Phone: 630-980-3880
  • Fax: 630-980-4828
Mailing address:
  • Phone: 630-980-3880
  • Fax: 630-980-4828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019020133
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN T EVANS
Title or Position: OWNER
Credential:
Phone: 630-980-3880