Healthcare Provider Details

I. General information

NPI: 1831409762
Provider Name (Legal Business Name): SHERMAN OAKS DENTAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SHERMAN AVE SUITE 103
NAPERVILLE IL
60563-8608
US

IV. Provider business mailing address

1100 SHERMAN AVE SUITE 103
NAPERVILLE IL
60563-8608
US

V. Phone/Fax

Practice location:
  • Phone: 630-369-5225
  • Fax:
Mailing address:
  • Phone: 630-369-5225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number019022305
License Number StateIL

VIII. Authorized Official

Name: DR. BRYAN A WEYNETH
Title or Position: OWNER/DENTIST
Credential:
Phone: 630-369-5225