=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669558250
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | H & H FAMILY DENTAL, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 01/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 HEARTLAND DR SUITE A
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61704-7741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-662-0523
-----------------------------------------------------
Fax | 309-662-7693
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 HEARTLAND DR SUITE A
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61704-7741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-662-0523
-----------------------------------------------------
Fax | 309-662-7693
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JULIE LIPIC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-662-0523
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019-025505
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------