Healthcare Provider Details

I. General information

NPI: 1609877455
Provider Name (Legal Business Name): DENNIS E DETTMANN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21219 SILKTREE CIR
PLAINFIELD IL
60544-9359
US

IV. Provider business mailing address

21219 SILKTREE CIR
PLAINFIELD IL
60544-9359
US

V. Phone/Fax

Practice location:
  • Phone: 630-257-6493
  • Fax: 630-243-6293
Mailing address:
  • Phone: 630-257-6493
  • Fax: 630-243-6293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007054
License Number StateIL

VII. Legacy identifiers

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

# 1
Identifier046007054
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: