Healthcare Provider Details

I. General information

NPI: 1699240416
Provider Name (Legal Business Name): ELGIN DENTAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 SUMMIT ST STE 105
ELGIN IL
60120-3861
US

IV. Provider business mailing address

1699 E WOODFIELD RD STE 102
SCHAUMBURG IL
60173-4955
US

V. Phone/Fax

Practice location:
  • Phone: 847-742-6717
  • Fax:
Mailing address:
  • Phone: 630-339-3172
  • Fax: 630-891-6775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTY WOLTER
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 630-339-3172