Healthcare Provider Details

I. General information

NPI: 1134537889
Provider Name (Legal Business Name): KIDS PLUS PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2014
Last Update Date: 07/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1786 MOON LAKE BLVD SUITE 216
HOFFMAN ESTATES IL
60169-5029
US

IV. Provider business mailing address

1786 MOON LAKE BLVD SUITE 216
HOFFMAN ESTATES IL
60169-5029
US

V. Phone/Fax

Practice location:
  • Phone: 847-882-2555
  • Fax: 847-628-1438
Mailing address:
  • Phone: 847-882-2555
  • Fax: 847-628-1438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number019023892
License Number StateIL

VIII. Authorized Official

Name: DR. DENISE FISHER
Title or Position: PRESIDENT
Credential:
Phone: 847-882-2555