Healthcare Provider Details

I. General information

NPI: 1386201622
Provider Name (Legal Business Name): PROGRESSIVE DENTAL & ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20402 CRAWFORD AVE
MATTESON IL
60443-1734
US

IV. Provider business mailing address

20402 CRAWFORD AVE
MATTESON IL
60443-1734
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-4294
  • Fax: 708-747-5223
Mailing address:
  • Phone: 708-747-4294
  • Fax: 708-747-5223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ROBERT DERELL DURR
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 708-747-4294