Healthcare Provider Details

I. General information

NPI: 1073108841
Provider Name (Legal Business Name): SAUK TRAIL DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4343 SAUK TRL
RICHTON PARK IL
60471-1254
US

IV. Provider business mailing address

4343 SAUK TRL
RICHTON PARK IL
60471-1254
US

V. Phone/Fax

Practice location:
  • Phone: 708-608-3368
  • Fax:
Mailing address:
  • Phone: 708-608-3368
  • Fax:

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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LAWAL GARUBA
Title or Position: DENTIST
Credential: DMD
Phone: 708-608-3368