Healthcare Provider Details

I. General information

NPI: 1972392751
Provider Name (Legal Business Name): CRYSTAL COVE FAMILY DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2025
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15614 S HARLEM AVE STE A
ORLAND PARK IL
60462-4401
US

IV. Provider business mailing address

15614 S HARLEM AVE STE A
ORLAND PARK IL
60462-4401
US

V. Phone/Fax

Practice location:
  • Phone: 708-614-1111
  • Fax: 708-614-1117
Mailing address:
  • Phone: 708-614-1111
  • Fax: 708-614-1117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: FLORENTINA CAMACHO
Title or Position: OFFICE MANAGER
Credential:
Phone: 708-614-1111