Provider Demographics
NPI:1124124821
Name:PRENDERGAST, THOMAS LOVE
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LOVE
Last Name:PRENDERGAST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:866 N AUBURN WOODS DR
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-8662
Mailing Address - Country:US
Mailing Address - Phone:847-202-5813
Mailing Address - Fax:
Practice Address - Street 1:1394 S ROUTE 12
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1949
Practice Address - Country:US
Practice Address - Phone:847-587-5053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022387122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist