=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962531277
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODRIDGE DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2007
-----------------------------------------------------
Last Update Date | 09/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2839 83RD ST
-----------------------------------------------------
City | DARIEN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60561-5612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-985-5000
-----------------------------------------------------
Fax | 630-985-5047
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2839 83RD ST
-----------------------------------------------------
City | DARIEN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60561-5612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-985-5000
-----------------------------------------------------
Fax | 630-985-5047
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. PATRICK J FLEMING
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 630-985-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------