=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205207859
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | USP DENTAL ASSOCIATES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2015
-----------------------------------------------------
Last Update Date | 10/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 TOWNHALL DR
-----------------------------------------------------
City | ROMEOVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60446-1338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-886-0875
-----------------------------------------------------
Fax | 815-886-0075
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 TOWNHALL DR
-----------------------------------------------------
City | ROMEOVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60446-1338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-886-0875
-----------------------------------------------------
Fax | 815-886-0075
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. UMANG PATEL
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 815-886-0875
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019025420
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------