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General NPI Number Information
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NPI Number | 1669924833
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Entity Type | Organization
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Legal Business Name | LLCDENTAL,
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Dates
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Enumeration Date | 11/03/2016
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Last Update Date | 11/03/2016
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Provider Practice Location Address
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Address Line | 3494 VOLLMER RD
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City | OLYMPIA FIELDS
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State | IL
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Zip | 60461-1018
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Country | US
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Telephone | 708-747-2273
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Fax | 708-747-2238
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Provider Business Mailing Address
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Address Line | 3494 VOLLMER RD
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City | OLYMPIA FIELDS
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State | IL
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Zip | 60461-1018
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Country | US
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Telephone | 708-747-2273
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Fax | 708-747-2238
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Authorized Official
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Title or Position | MANAGER
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Name | MR. KEVIN DALE MIMMS
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Credential | M.S.
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Telephone | 708-747-2273
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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 | 019020348
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License Number State | IL
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