Healthcare Provider Details

I. General information

NPI: 1801022462
Provider Name (Legal Business Name): FAMILIA DENTAL WHEELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 W. DUNDEE ROAD
WHEELING IL
60090-3227
US

IV. Provider business mailing address

2050 EAST ALGONQUIN ROAD SUITE 610
SCHAUMBURG IL
60173-4166
US

V. Phone/Fax

Practice location:
  • Phone: 847-453-7396
  • Fax: 847-453-7396
Mailing address:
  • Phone: 847-453-7396
  • Fax: 847-453-7396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019026020
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRANDON ALEXANDER TAYLOR
Title or Position: CREDENTIALING & PAYER RELATIONS MAN
Credential: CPCS
Phone: 847-453-7396