=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881168532
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL LOFT KIDS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2019
-----------------------------------------------------
Last Update Date | 01/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 W HARRIS AVE STE 2A
-----------------------------------------------------
City | LA GRANGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60525-2497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-482-0702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 W HARRIS AVE STE 2A
-----------------------------------------------------
City | LA GRANGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60525-2497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-482-0702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DR. KILEY HIRONS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 708-482-0702
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------