Provider Demographics
NPI:1215206842
Name:WILLOW RIDGE DENTAL GROUP LLC
Entity type:Organization
Organization Name:WILLOW RIDGE DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:ONIK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:630-420-2800
Mailing Address - Street 1:720 BROM CT
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6531
Mailing Address - Country:US
Mailing Address - Phone:630-420-2800
Mailing Address - Fax:
Practice Address - Street 1:720 BROM CT
Practice Address - Street 2:SUITE 105
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6531
Practice Address - Country:US
Practice Address - Phone:630-420-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty