Provider Demographics
NPI:1104954478
Name:INTERNATIONAL DENTAL PROFESSIONALS
Entity type:Organization
Organization Name:INTERNATIONAL DENTAL PROFESSIONALS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERUYUKI
Authorized Official - Middle Name:
Authorized Official - Last Name:HATAKEYAMA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-669-4088
Mailing Address - Street 1:9411 ACKMAN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-9706
Mailing Address - Country:US
Mailing Address - Phone:847-669-4088
Mailing Address - Fax:847-669-4018
Practice Address - Street 1:9411 ACKMAN RD
Practice Address - Street 2:
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156-9706
Practice Address - Country:US
Practice Address - Phone:847-669-4088
Practice Address - Fax:847-669-4018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty