Healthcare Provider Details

I. General information

NPI: 1154712784
Provider Name (Legal Business Name): EDP OF ILLINOIS P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2015
Last Update Date: 09/29/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 S MAIN ST
DUPO IL
62239-1347
US

IV. Provider business mailing address

141 W JACKSON BLVD STE 210
CHICAGO IL
60604-3048
US

V. Phone/Fax

Practice location:
  • Phone: 312-800-1270
  • Fax:
Mailing address:
  • Phone: 312-800-1270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021.001656
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA GARIBAY
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 312-736-8963