Provider Demographics
NPI:1447670054
Name:PERFORMACE DENTAL CARE IL PC
Entity type:Organization
Organization Name:PERFORMACE DENTAL CARE IL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:FATLAND
Authorized Official - Last Name:FATLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-464-8850
Mailing Address - Street 1:7230 191ST ST
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-9378
Mailing Address - Country:US
Mailing Address - Phone:815-464-8850
Mailing Address - Fax:
Practice Address - Street 1:7230 191ST ST
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-9378
Practice Address - Country:US
Practice Address - Phone:815-464-8850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19025070122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01902570Medicaid