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General NPI Number Information
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NPI Number | 1710143243
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Entity Type | Organization
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Legal Business Name | SQUAW GROVE DENTAL
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Dates
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Enumeration Date | 08/04/2008
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 165 W LINCOLN AVE
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City | HINCKLEY
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State | IL
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Zip | 60520-9207
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Country | US
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Telephone | 815-286-3303
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Fax | 815-286-9249
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Provider Business Mailing Address
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Address Line | 165 W LINCOLN AVE
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City | HINCKLEY
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State | IL
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Zip | 60520-9207
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Country | US
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Telephone | 815-286-3303
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Fax | 815-286-9249
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Authorized Official
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Title or Position | DDS
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Name | KEITH A BARNHART
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Credential |
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Telephone | 815-286-3303
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State | IL
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