Provider Demographics
NPI:1114803822
Name:LAGRANGE PARK DENTISTRY PC
Entity type:Organization
Organization Name:LAGRANGE PARK DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:708-846-3436
Mailing Address - Street 1:5924 TYLER DR
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1007
Mailing Address - Country:US
Mailing Address - Phone:708-846-3436
Mailing Address - Fax:
Practice Address - Street 1:360 SHERWOOD RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1967
Practice Address - Country:US
Practice Address - Phone:708-354-7363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental