Healthcare Provider Details

I. General information

NPI: 1669924833
Provider Name (Legal Business Name): LLCDENTAL,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3494 VOLLMER RD
OLYMPIA FIELDS IL
60461-1018
US

IV. Provider business mailing address

3494 VOLLMER RD
OLYMPIA FIELDS IL
60461-1018
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-2273
  • Fax: 708-747-2238
Mailing address:
  • Phone: 708-747-2273
  • Fax: 708-747-2238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019020348
License Number StateIL

VIII. Authorized Official

Name: MR. KEVIN DALE MIMMS
Title or Position: MANAGER
Credential: M.S.
Phone: 708-747-2273