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General NPI Number Information
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NPI Number | 1972392751
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Entity Type | Organization
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Legal Business Name | CRYSTAL COVE FAMILY DENTAL PLLC
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Dates
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Enumeration Date | 05/06/2025
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Last Update Date | 05/06/2025
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Provider Practice Location Address
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Address Line | 15614 S HARLEM AVE STE A
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City | ORLAND PARK
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State | IL
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Zip | 60462-4401
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Country | US
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Telephone | 708-614-1111
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Fax | 708-614-1117
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Provider Business Mailing Address
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Address Line | 15614 S HARLEM AVE STE A
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City | ORLAND PARK
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State | IL
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Zip | 60462-4401
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Country | US
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Telephone | 708-614-1111
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Fax | 708-614-1117
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | FLORENTINA CAMACHO
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Credential |
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Telephone | 708-614-1111
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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