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General NPI Number Information
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NPI Number | 1013462175
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Entity Type | Organization
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Legal Business Name | 5 STAR FAMILY DENTAL
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Dates
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Enumeration Date | 08/18/2016
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Last Update Date | 02/03/2017
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Provider Practice Location Address
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Address Line | 615 E 162ND ST
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City | SOUTH HOLLAND
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State | IL
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Zip | 60473-2329
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Country | US
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Telephone | 708-331-1900
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Fax |
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Provider Business Mailing Address
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Address Line | 615 E 162ND ST
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City | SOUTH HOLLAND
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State | IL
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Zip | 60473-2329
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Country | US
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Telephone | 708-331-1900
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Fax |
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Authorized Official
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Title or Position | DENTIST / OWNER
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Name | DR. KEVIN LLOYD FATLAND
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Credential | DMD
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Telephone | 708-990-7869
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019025070
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License Number State | IL
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