Healthcare Provider Details

I. General information

NPI: 1659821312
Provider Name (Legal Business Name): ILLINOIS DENTAL PROVIDERS, P. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 03/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12720 S ROUTE 59 SUITE 200
PLAINFIELD IL
60585-5505
US

IV. Provider business mailing address

7160 DALLAS PKWY STE 400
PLANO TX
75024-7111
US

V. Phone/Fax

Practice location:
  • Phone: 972-755-0883
  • Fax: 216-584-1750
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: RACHEL NITTINGER
Title or Position: MANAGER CREDENTIALING
Credential:
Phone: 972-755-0816