Healthcare Provider Details

I. General information

NPI: 1225172323
Provider Name (Legal Business Name): AHOYT FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13717 S US 30 UNIT 129
PLAINFIELD IL
60544-5527
US

IV. Provider business mailing address

13717 S.US 30 UNIT 129
PLAINFIELD IL
60544
US

V. Phone/Fax

Practice location:
  • Phone: 815-436-3377
  • Fax: 815-436-6599
Mailing address:
  • Phone: 815-436-3377
  • Fax: 815-436-6599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019025441
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CARMEN IRIS GONZALEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 815-436-3377