Healthcare Provider Details

I. General information

NPI: 1114803822
Provider Name (Legal Business Name): LAGRANGE PARK DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2025
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 SHERWOOD RD
LA GRANGE PARK IL
60526-1967
US

IV. Provider business mailing address

5924 TYLER DR
WOODRIDGE IL
60517-1007
US

V. Phone/Fax

Practice location:
  • Phone: 708-354-7363
  • Fax:
Mailing address:
  • Phone: 708-846-3436
  • Fax:

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: DR. RYAN PETERSON
Title or Position: PRESIDENT/OWNER
Credential: DMD
Phone: 708-846-3436