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General NPI Number Information
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NPI Number | 1699039875
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Entity Type | Organization
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Legal Business Name | PEDIATRIC AND FAMILY DENT
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Dates
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Enumeration Date | 07/02/2012
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Last Update Date | 07/02/2012
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Provider Practice Location Address
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Address Line | 38 PLYMOUTH CT
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City | LINCOLNSHIRE
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State | IL
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Zip | 60069-3157
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Country | US
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Telephone | 312-310-4543
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Fax |
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Provider Business Mailing Address
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Address Line | 38 PLYMOUTH CT
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City | LINCOLNSHIRE
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State | IL
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Zip | 60069-3157
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Country | US
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Telephone | 312-310-4543
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | SCOTT GOLDMAN
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Credential |
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Telephone | 312-310-4543
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 019027333
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License Number State | IL
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