Healthcare Provider Details

I. General information

NPI: 1932959723
Provider Name (Legal Business Name): GE KIDDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 S PARK BLVD
GLEN ELLYN IL
60137-6211
US

IV. Provider business mailing address

640 S MONROE ST
HINSDALE IL
60521-3926
US

V. Phone/Fax

Practice location:
  • Phone: 402-659-6054
  • Fax:
Mailing address:
  • Phone: 402-659-6054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SANDRA TRINH
Title or Position: MANAGING MEMBER
Credential:
Phone: 402-659-6054