Healthcare Provider Details

I. General information

NPI: 1457589715
Provider Name (Legal Business Name): DRFLASH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23657 W ORCHARD LN
PLAINFIELD IL
60586-8012
US

IV. Provider business mailing address

23657 W ORCHARD LN
PLAINFIELD IL
60586-8012
US

V. Phone/Fax

Practice location:
  • Phone: 630-878-0351
  • Fax: 815-254-9746
Mailing address:
  • Phone: 630-878-0351
  • Fax: 815-254-9746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019020648
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code292200000X
TaxonomyDental Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN A GORDON JR.
Title or Position: OFFICER
Credential: D.M.D.
Phone: 630-878-0351