=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013632801
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL PROFESSIONALS OF ILLINOIS, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2022
-----------------------------------------------------
Last Update Date | 10/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95 S WAUKEGAN RD
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-5204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-515-7390
-----------------------------------------------------
Fax | 224-300-6393
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 95 S WAUKEGAN RD
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-5204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-515-7390
-----------------------------------------------------
Fax | 224-300-6393
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | BELINDA HUERTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-540-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------