Healthcare Provider Details

I. General information

NPI: 1982772554
Provider Name (Legal Business Name): LORI JOANN JEPSEN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 S MAIN ST GROVE DENTAL ASSOC 3RD FLOOR
DOWNERS GROVE IL
60516
US

IV. Provider business mailing address

2913 VIMY RIDGE
JOLIET IL
60435
US

V. Phone/Fax

Practice location:
  • Phone: 630-969-5350
  • Fax:
Mailing address:
  • Phone: 815-436-1165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: