Provider Demographics
NPI:1104974708
Name:GLENWOOD DENTAL PC
Entity type:Organization
Organization Name:GLENWOOD DENTAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUBBASHINI
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIMUTHU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:630-545-1116
Mailing Address - Street 1:1155 N MAIN ST
Mailing Address - Street 2:STE A
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-3508
Mailing Address - Country:US
Mailing Address - Phone:630-545-1116
Mailing Address - Fax:630-545-1117
Practice Address - Street 1:1155 N MAIN ST
Practice Address - Street 2:STE A
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-3508
Practice Address - Country:US
Practice Address - Phone:630-545-1116
Practice Address - Fax:630-545-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty