Provider Demographics
NPI:1487731808
Name:GLEN ELLYN FAMILY DENTAL CARE
Entity type:Organization
Organization Name:GLEN ELLYN FAMILY DENTAL CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SANSONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-858-0216
Mailing Address - Street 1:658 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137
Mailing Address - Country:US
Mailing Address - Phone:630-858-0216
Mailing Address - Fax:630-858-0022
Practice Address - Street 1:658 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137
Practice Address - Country:US
Practice Address - Phone:630-858-0216
Practice Address - Fax:630-858-0022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023247122300000X
IL019021405122300000X
IL019019339122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty