Healthcare Provider Details

I. General information

NPI: 1376869024
Provider Name (Legal Business Name): MOBILE MEDICAL AND DENTAL SERVICES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 04/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9716 S LONGWOOD DR
CHICAGO IL
60643-1610
US

IV. Provider business mailing address

9716 S LONGWOOD DR
CHICAGO IL
60643-1610
US

V. Phone/Fax

Practice location:
  • Phone: 708-250-6175
  • Fax:
Mailing address:
  • Phone: 708-250-6175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.021712
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.074856
License Number StateIL

VIII. Authorized Official

Name: DR. WILLIAM CREVIER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 708-250-6175