Provider Demographics
NPI:1104302439
Name:HARLEM IRVING FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:HARLEM IRVING FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-869-5857
Mailing Address - Street 1:1699 E WOODFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4947
Mailing Address - Country:US
Mailing Address - Phone:630-689-5857
Mailing Address - Fax:
Practice Address - Street 1:7601 W IRVING PARK RD STE 102
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2140
Practice Address - Country:US
Practice Address - Phone:773-589-9220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19017598261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental