Healthcare Provider Details

I. General information

NPI: 1861684300
Provider Name (Legal Business Name): SUGAR GROVE DENTAL ASSOCIATES,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 08/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 NORTH ROUTE 47 SUITE J
SUGAR GROVE IL
60554
US

IV. Provider business mailing address

495 NORTH ROUTE 47 SUITE J
SUGAR GROVE IL
60554
US

V. Phone/Fax

Practice location:
  • Phone: 630-466-1100
  • Fax: 630-810-9922
Mailing address:
  • Phone: 630-466-1100
  • Fax: 630-810-9922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. GLENN LOUIS DEWEIRDT JR.
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 630-466-1100