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1402 S Us Highway 12 Fox Lake IL 60020-1252 | |
| (217) 540-5100 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 1402 S Us Highway 12, Fox Lake, Illinois |
| Authorized Official Name and Position | Jessica Britt (CREDENTIALING COORDINATOR) |
| Authorized Official Contact | 2175408426 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
1402 S Us Highway 12 Fox Lake IL 60020-1252 Ph: (847) 973-6765 | 1402 S Us Highway 12 Fox Lake IL 60020-1252 Ph: (217) 540-5100 |
| NPI Number | 1790262434 |
|---|---|
| Provider Enumeration Date | 07/25/2018 |
| Last Update Date | 10/03/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1790262434 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | (* (Not Available)) | Primary |
Thomas L. Prendergast, Dds, Pc Dental Clinic Medicare: Not Enrolled in Medicare Practice Location: 1394 S Route 12, Fox Lake, IL 60020 Phone: 847-587-5053 | |