Healthcare Provider Details

I. General information

NPI: 1821240169
Provider Name (Legal Business Name): TONGUE N CHIC DENTAL BOUTIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 10/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 DOUGLAS AVE
ELGIN IL
60120-5546
US

IV. Provider business mailing address

14 DOUGLAS AVE
ELGIN IL
60120-5546
US

V. Phone/Fax

Practice location:
  • Phone: 847-841-6665
  • Fax: 847-841-6656
Mailing address:
  • Phone: 847-841-6665
  • Fax: 847-841-6656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRANDON FARLEY BECKER
Title or Position: CEO/OWNER
Credential: DDS
Phone: 847-841-6665