=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285016709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OAK MILL FAMILY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2015
-----------------------------------------------------
Last Update Date | 06/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7900 N MILWAUKEE AVE SUITE 2-30A
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60714-3159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-965-4300
-----------------------------------------------------
Fax | 866-830-0746
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7900 N MILWAUKEE AVE SUITE 2-30A
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60714-3159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-965-4300
-----------------------------------------------------
Fax | 866-830-0746
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTAL
-----------------------------------------------------
Name | PAUL THEODORE ANAST
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 847-965-4300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019027804
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------