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General NPI Number Information
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NPI Number | 1285985549
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Entity Type | Organization
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Legal Business Name | STRATFORD DENTAL PC
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Dates
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Enumeration Date | 09/27/2012
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Last Update Date | 01/14/2016
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Provider Practice Location Address
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Address Line | 290 SPRINGFIELD DR SUITE #130
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-2214
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Country | US
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Telephone | 630-980-3880
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Fax | 630-980-4828
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Provider Business Mailing Address
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Address Line | 290 SPRINGFIELD DR SUITE #130
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-2214
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Country | US
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Telephone | 630-980-3880
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Fax | 630-980-4828
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRIAN T EVANS
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Credential |
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Telephone | 630-980-3880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019020133
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License Number State | IL
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