=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629508734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYER FAMILY DENTAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2017
-----------------------------------------------------
Last Update Date | 06/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 890 RICHARD RD
-----------------------------------------------------
City | DYER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46311-1779
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-869-8662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7855 PINEVIEW LN
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-9004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-839-8662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/PRESIDENT
-----------------------------------------------------
Name | KEVIN LLOYD FATLAND
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 708-839-8662
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 19025070
-----------------------------------------------------
License Number State |
-----------------------------------------------------