Healthcare Provider Details

I. General information

NPI: 1982197984
Provider Name (Legal Business Name): MCHENRY DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 N RIVERSIDE DR
MCHENRY IL
60050-4509
US

IV. Provider business mailing address

1699 E WOODFIELD RD STE 102
SCHAUMBURG IL
60173-4955
US

V. Phone/Fax

Practice location:
  • Phone: 815-385-1360
  • Fax:
Mailing address:
  • Phone: 630-339-3172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number019021569
License Number StateIL

VIII. Authorized Official

Name: KRISTY WOLTER
Title or Position: INSURANCE MANAGER
Credential:
Phone: 630-869-5857