Provider Demographics
NPI:1043352354
Name:ABC DENTISTRY, LTD.
Entity type:Organization
Organization Name:ABC DENTISTRY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-882-3360
Mailing Address - Street 1:80 W HILLCREST BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60195-3111
Mailing Address - Country:US
Mailing Address - Phone:847-882-3360
Mailing Address - Fax:847-882-3383
Practice Address - Street 1:80 W HILLCREST BLVD STE 212
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60195
Practice Address - Country:US
Practice Address - Phone:847-882-3360
Practice Address - Fax:847-882-3383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0218721223G0001X
IL019.0218681223P0221X
IL019.0236461223P0221X
IL019.0264641223P0221X
IL019.0152371223P0221X
IL019.0257111223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019.021868Medicaid