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General NPI Number Information
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NPI Number | 1811107998
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Entity Type | Organization
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Legal Business Name | GLEN ELLYN ORTHODONTIC ASSOCIATES, P.C.
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 01/08/2009
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Provider Practice Location Address
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Address Line | 507 DUANE ST
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City | GLEN ELLYN
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State | IL
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Zip | 60137-4549
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Country | US
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Telephone | 630-469-5225
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Fax | 630-469-5443
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Provider Business Mailing Address
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Address Line | 507 DUANE ST
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City | GLEN ELLYN
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State | IL
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Zip | 60137-4549
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Country | US
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Telephone | 630-469-5225
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Fax | 630-469-5443
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Authorized Official
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Title or Position | OWNER
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Name | DR. DOUGLAS ROBERT PRINCE
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Credential | DDS,MS,PC
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Telephone | 630-469-5225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 019-014235
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License Number State | IL
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