Healthcare Provider Details

I. General information

NPI: 1134376189
Provider Name (Legal Business Name): WESTLAKE DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2008
Last Update Date: 08/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 WASHINGTON ST
INGLESIDE IL
60041-9208
US

IV. Provider business mailing address

214 WASHINGTON ST
INGLESIDE IL
60041-9208
US

V. Phone/Fax

Practice location:
  • Phone: 847-587-3020
  • Fax: 847-587-1598
Mailing address:
  • Phone: 847-587-3020
  • Fax: 847-587-1598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019026900
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019025326
License Number StateIL

VIII. Authorized Official

Name: DR. MIN J KWON
Title or Position: OWNER
Credential: D.D.S.
Phone: 847-587-3020