| Providence Family Dental | |
|
3091 W. Route 20 #103 Elgin IL 60124 | |
| (847) 841-1555 | |
| Not Available |
| Full Name | Providence Family Dental |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 3091 W. Route 20, Elgin, Illinois |
| Authorized Official Name and Position | Siri Chanthasalo (PRESIDENT) |
| Authorized Official Contact | 8472177215 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Providence Family Dental 452 Westport Dr Pingree Grove IL 60140-9172 Ph: (847) 217-7215 | Providence Family Dental 3091 W. Route 20 #103 Elgin IL 60124 Ph: (847) 841-1555 |
| NPI Number | 1114178183 |
|---|---|
| Provider Enumeration Date | 10/08/2008 |
| Last Update Date | 10/08/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1114178183 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | 019.025831 (Illinois) | Primary |
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