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General NPI Number Information
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NPI Number | 1568751436
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Entity Type | Organization
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Legal Business Name | LONG GROVE DENTAL STUDIO
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Dates
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Enumeration Date | 03/31/2011
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Last Update Date | 03/31/2011
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Provider Practice Location Address
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Address Line | 3976 ROUTE 22 SUITE E
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City | LONG GROVE
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State | IL
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Zip | 60047
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Country | US
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Telephone | 847-719-1973
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Fax | 847-719-1975
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Provider Business Mailing Address
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Address Line | 3976 ROUTE 22 SUITE E
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City | LONG GROVE
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State | IL
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Zip | 60047
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Country | US
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Telephone | 847-719-1973
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Fax | 847-719-1975
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. NICHOLE LEE DEMARS
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Credential | DDS
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Telephone | 847-719-1973
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019025986
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License Number State | IL
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