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General NPI Number Information
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NPI Number | 1083069199
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Entity Type | Organization
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Legal Business Name | DENTAL LOFT - THE LOOP
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Dates
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Enumeration Date | 04/26/2016
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Last Update Date | 04/26/2016
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Provider Practice Location Address
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Address Line | 111 W WASHINGTON ST SUITE 1350
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City | CHICAGO
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State | IL
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Zip | 60602-2703
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Country | US
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Telephone | 708-482-0702
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Fax |
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Provider Business Mailing Address
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Address Line | 1 W HARRIS AVE STE 2A
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City | LA GRANGE
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State | IL
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Zip | 60525-2497
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Country | US
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Telephone | 708-482-0702
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. KILEY HIRONS
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Credential | DDS
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Telephone | 708-482-0702
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.027663
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License Number State | IL
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