Healthcare Provider Details

I. General information

NPI: 1659921575
Provider Name (Legal Business Name): OLYMPIA FIELDS FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20180 GOVERNORS HWY STE 104
OLYMPIA FIELDS IL
60461-1065
US

IV. Provider business mailing address

20180 GOVERNORS HWY STE 104
OLYMPIA FIELDS IL
60461-1065
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-9777
  • Fax:
Mailing address:
  • Phone: 708-747-9777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KRISTY WOLTER
Title or Position: INSURANCE MANAGER
Credential:
Phone: 630-339-3172