Healthcare Provider Details

I. General information

NPI: 1013155191
Provider Name (Legal Business Name): THERESE M. BOGS, D.D.S., LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2009
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 W MONEE MANHATTAN RD STE 117
MONEE IL
60449-8866
US

IV. Provider business mailing address

26634 S WINFIELD RD
MONEE IL
60449-9220
US

V. Phone/Fax

Practice location:
  • Phone: 708-534-9700
  • Fax: 708-534-9228
Mailing address:
  • Phone: 708-534-7818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number019-022073
License Number StateIL

VIII. Authorized Official

Name: DR. THERESE MARIE BOGS
Title or Position: PRESIDENT
Credential: DDS
Phone: 708-534-9700