Healthcare Provider Details

I. General information

NPI: 1326400078
Provider Name (Legal Business Name): 590 DENTAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 WILLIAM R LATHAM SR DR
BOURBONNAIS IL
60914-2320
US

IV. Provider business mailing address

129 S ROSELLE RD SUITE 102
SCHAUMBURG IL
60193-5540
US

V. Phone/Fax

Practice location:
  • Phone: 630-339-3172
  • Fax:
Mailing address:
  • Phone: 630-339-3172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number019018431
License Number StateIL

VIII. Authorized Official

Name: DR. ALAN J ACIERNO
Title or Position: MANAGER
Credential: DDS
Phone: 630-339-3172