Healthcare Provider Details

I. General information

NPI: 1891843637
Provider Name (Legal Business Name): DRS. SLABY, ADAMS AND TIETJENS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 03/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 ALMAR PKWY SUITE 102
BOURBONNAIS IL
60914-2315
US

IV. Provider business mailing address

750 ALMAR PKWY SUITE 102
BOURBONNAIS IL
60914-2315
US

V. Phone/Fax

Practice location:
  • Phone: 815-939-7136
  • Fax: 815-939-9820
Mailing address:
  • Phone: 815-939-7136
  • Fax: 815-939-9820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number060002115
License Number StateIL

VIII. Authorized Official

Name: DR. JAMES MATTHEW ADAMS
Title or Position: PRESIDENT
Credential: DDS
Phone: 815-939-7136