Healthcare Provider Details

I. General information

NPI: 1306853429
Provider Name (Legal Business Name): WINTHROP HARBOR DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

644 SHERIDAN RD SUITE 105
WINTHROP HARBOR IL
60096-1350
US

IV. Provider business mailing address

644 SHERIDAN RD SUITE 105
WINTHROP HARBOR IL
60096-1350
US

V. Phone/Fax

Practice location:
  • Phone: 847-872-5626
  • Fax: 847-746-2900
Mailing address:
  • Phone: 847-872-5626
  • Fax: 847-746-2900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019015026
License Number StateIL

VIII. Authorized Official

Name: MRS. MICHELLE L OPELT
Title or Position: BUSINESS MANAGER
Credential:
Phone: 847-872-5626