Healthcare Provider Details

I. General information

NPI: 1811408453
Provider Name (Legal Business Name): ELMHURST DENTAL GROUP LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W MAIN ST
WEST DUNDEE IL
60118-2026
US

IV. Provider business mailing address

333 W 1ST ST
ELMHURST IL
60126-2641
US

V. Phone/Fax

Practice location:
  • Phone: 847-426-5030
  • Fax:
Mailing address:
  • Phone: 630-833-5110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARY BETH WALTER
Title or Position: CFO
Credential:
Phone: 630-833-5110