=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649378571
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIDDEN LAKES DENTAL CARE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 04/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 680 W BOUGHTON RD
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60440-2185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-759-0077
-----------------------------------------------------
Fax | 630-759-0082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 680 W BOUGHTON RD
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60440-2185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-759-0077
-----------------------------------------------------
Fax | 630-759-0082
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHARLES E CROWL
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 630-759-0077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 060-007659
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------