Healthcare Provider Details

I. General information

NPI: 1063791218
Provider Name (Legal Business Name): MALTA FAMILY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 08/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 VAN BUREN ST
MALTA IL
60150-9512
US

IV. Provider business mailing address

304 VAN BUREN ST
MALTA IL
60150-9512
US

V. Phone/Fax

Practice location:
  • Phone: 815-825-5025
  • Fax: 815-516-0205
Mailing address:
  • Phone: 815-825-5025
  • Fax: 815-516-0205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019027588
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020010952
License Number StateIL

VIII. Authorized Official

Name: MRS. ANNE ELIZABETH ANDERSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 815-825-5025