Healthcare Provider Details

I. General information

NPI: 1689326175
Provider Name (Legal Business Name): ILLINOIS DENTAL PROFESSIONALS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S MAIN ST
NAPERVILLE IL
60540-5322
US

IV. Provider business mailing address

405 S MAIN ST
NAPERVILLE IL
60540-5322
US

V. Phone/Fax

Practice location:
  • Phone: 630-357-7273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: HILLARY THULL
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-8946