Healthcare Provider Details

I. General information

NPI: 1982094462
Provider Name (Legal Business Name): FAMILIA DENTAL CHAMPAIGN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 W. SPRINGFIELD AVE
CHAMPAIGN IL
61821-3011
US

IV. Provider business mailing address

2050 E ALGONQUIN RD SUITE 610
SCHAUMBURG IL
60173-4144
US

V. Phone/Fax

Practice location:
  • Phone: 217-355-6396
  • Fax: 217-355-6872
Mailing address:
  • Phone: 888-988-4066
  • Fax: 847-496-4850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019026920
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRANDON ALEXANDER TAYLOR
Title or Position: CREDENTIALING PAYER RELATIONS MGR
Credential: CPCS
Phone: 847-453-7396