Healthcare Provider Details

I. General information

NPI: 1023007234
Provider Name (Legal Business Name): CARPENTERSVILLE DENTAL CARE, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S KENNEDY DR SUITE 23 A
CARPENTERSVILLE IL
60110-2091
US

IV. Provider business mailing address

150 S KENNEDY DR SUITE 23 A
CARPENTERSVILLE IL
60110-2091
US

V. Phone/Fax

Practice location:
  • Phone: 847-551-1199
  • Fax: 847-783-5282
Mailing address:
  • Phone: 847-551-1199
  • Fax: 847-783-5282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. SONGCHIN YU
Title or Position: PRESIDENT
Credential: D.D.S
Phone: 847-551-1199