Healthcare Provider Details

I. General information

NPI: 1609199165
Provider Name (Legal Business Name): AVID DENTAL LINDENHURST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2010
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2246 E. GRAND AVE
LAKE VILLA IL
60046
US

IV. Provider business mailing address

2246 E. GRAND AVE
LAKE VILLA IL
60046
US

V. Phone/Fax

Practice location:
  • Phone: 847-265-6444
  • Fax: 847-265-6464
Mailing address:
  • Phone: 847-265-6444
  • Fax: 847-265-6464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MEENAL L GOEL
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 847-530-2828