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General NPI Number Information
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NPI Number | 1447657234
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Entity Type | Organization
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Legal Business Name | GREAT LAKES DENTAL P.C.
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Dates
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Enumeration Date | 11/23/2014
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Last Update Date | 12/16/2014
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Provider Practice Location Address
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Address Line | 1418 S MILWAUKEE AVE SUITE 4
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City | LIBERTYVILLE
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State | IL
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Zip | 60048-3796
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Country | US
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Telephone | 815-209-6272
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Fax |
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Provider Business Mailing Address
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Address Line | 1418 S MILWAUKEE AVE SUITE 4
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City | LIBERTYVILLE
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State | IL
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Zip | 60048-3796
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT / DENTIST
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Name | DR. ANSHUMAN SONI
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Credential | DDS
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Telephone | 815-209-6272
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 019026289
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License Number State | IL
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