Provider Demographics
NPI:1194156844
Name:LEMONT FAMILY DENTAL, LTD
Entity type:Organization
Organization Name:LEMONT FAMILY DENTAL, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:SPLITT-KRULL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-257-8669
Mailing Address - Street 1:160 E WEND ST STE B
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-2904
Mailing Address - Country:US
Mailing Address - Phone:630-257-8669
Mailing Address - Fax:630-257-9255
Practice Address - Street 1:160 E WEND ST STE B
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-2904
Practice Address - Country:US
Practice Address - Phone:630-257-8669
Practice Address - Fax:630-257-9255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-06
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-022298122300000X
IL019022298332B00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6987150001OtherPTAN
IL6987150001Medicare NSC