Healthcare Provider Details

I. General information

NPI: 1548408438
Provider Name (Legal Business Name): FOREST ORTHODONTICS AND PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 S WAUKEGAN RD SUITE 101
LAKE FOREST IL
60045
US

IV. Provider business mailing address

810 S WAUKEGAN RD SUITE 101
LAKE FOREST IL
60045
US

V. Phone/Fax

Practice location:
  • Phone: 847-615-5437
  • Fax: 847-615-2955
Mailing address:
  • Phone: 847-615-5437
  • Fax: 847-615-2955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number021002150
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021002219
License Number StateIL

VIII. Authorized Official

Name: DR. ANOKHI D BOCK
Title or Position: OWNER / PARTNER
Credential: DMD
Phone: 847-234-6641