Healthcare Provider Details

I. General information

NPI: 1629508734
Provider Name (Legal Business Name): DYER FAMILY DENTAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 RICHARD RD
DYER IN
46311-1779
US

IV. Provider business mailing address

7855 PINEVIEW LN
FRANKFORT IL
60423-9004
US

V. Phone/Fax

Practice location:
  • Phone: 708-869-8662
  • Fax:
Mailing address:
  • Phone: 708-839-8662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19025070
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KEVIN LLOYD FATLAND
Title or Position: DENTIST/PRESIDENT
Credential: DMD
Phone: 708-839-8662