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General NPI Number Information
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NPI Number | 1376995688
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Entity Type | Organization
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Legal Business Name | FUNWAL LLC
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Dates
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Enumeration Date | 07/11/2016
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Last Update Date | 07/11/2016
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Provider Practice Location Address
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Address Line | 1695 ELK BLVD
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City | DES PLAINES
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State | IL
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Zip | 60016-4721
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Country | US
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Telephone | 847-727-8484
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Fax | 224-361-3611
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Provider Business Mailing Address
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Address Line | 1695 ELK BLVD
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City | DES PLAINES
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State | IL
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Zip | 60016-4721
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Country | US
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Telephone | 847-727-8484
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Fax | 224-361-3611
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MR. OLAWALE BABATUNDE
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Credential |
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Telephone | 847-827-8484
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019025347
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License Number State | IL
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