Healthcare Provider Details

I. General information

NPI: 1356719603
Provider Name (Legal Business Name): LAKEMOOR DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28956 W. RT 120
LAKEMOOR IL
60051
US

IV. Provider business mailing address

28956 W. RT 120
LAKEMOOR IL
60051
US

V. Phone/Fax

Practice location:
  • Phone: 815-363-8888
  • Fax: 815-363-8890
Mailing address:
  • Phone: 815-363-8888
  • Fax: 815-363-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019023300
License Number StateIL

VIII. Authorized Official

Name: DR. SIMA R PATEL
Title or Position: DENTIST
Credential: D.D.S.
Phone: 815-363-8888