Healthcare Provider Details

I. General information

NPI: 1194156844
Provider Name (Legal Business Name): LEMONT FAMILY DENTAL, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2013
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E WEND ST STE B
LEMONT IL
60439-2904
US

IV. Provider business mailing address

160 E WEND ST STE B
LEMONT IL
60439-2904
US

V. Phone/Fax

Practice location:
  • Phone: 630-257-8669
  • Fax: 630-257-9255
Mailing address:
  • Phone: 630-257-8669
  • Fax: 630-257-9255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019-022298
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number019022298
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number019022298
License Number StateIL

VIII. Authorized Official

Name: DR. JENNIFER L SPLITT-KRULL
Title or Position: PRESIDENT
Credential: DDS
Phone: 630-257-8669