Provider Demographics
NPI:1023175775
Name:LAGRANGE PERIODONTICS, LTD
Entity type:Organization
Organization Name:LAGRANGE PERIODONTICS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:P
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-354-4545
Mailing Address - Street 1:6520 JOLIET RD
Mailing Address - Street 2:
Mailing Address - City:COUNTRYSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-4649
Mailing Address - Country:US
Mailing Address - Phone:708-354-4545
Mailing Address - Fax:708-354-0336
Practice Address - Street 1:6520 JOLIET RD
Practice Address - Street 2:
Practice Address - City:COUNTRYSIDE
Practice Address - State:IL
Practice Address - Zip Code:60525
Practice Address - Country:US
Practice Address - Phone:708-354-4545
Practice Address - Fax:708-354-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL210014231223P0300X
IL210015611223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty