Healthcare Provider Details

I. General information

NPI: 1871826438
Provider Name (Legal Business Name): ELMHURST DENTAL GROUP, LTD DBA BLOOMINGDALE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 09/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 SPRINGFIELD DR SUITE 100
BLOOMINGDALE IL
60108-2214
US

IV. Provider business mailing address

333 W 1ST ST
ELMHURST IL
60126-2641
US

V. Phone/Fax

Practice location:
  • Phone: 630-529-0027
  • Fax: 630-529-0068
Mailing address:
  • Phone: 630-833-5110
  • Fax: 630-833-0458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. LAWRENCE P GROH
Title or Position: OWNER
Credential:
Phone: 630-833-5110