Healthcare Provider Details

I. General information

NPI: 1508384355
Provider Name (Legal Business Name): ROUTE 64 DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 08/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 W MAIN ST
ST CHARLES IL
60174-1814
US

IV. Provider business mailing address

1699 E WOODFIELD RD STE 102
SCHAUMBURG IL
60173-4955
US

V. Phone/Fax

Practice location:
  • Phone: 630-584-6177
  • Fax:
Mailing address:
  • Phone: 630-339-3172
  • Fax: 847-891-6775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019015977
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019012964
License Number StateIL

VIII. Authorized Official

Name: ALAN M ACIERNO
Title or Position: CFO
Credential:
Phone: 630-339-3172