Provider Demographics
NPI:1306172804
Name:ORLAND SQUARE DENTAL
Entity type:Organization
Organization Name:ORLAND SQUARE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GADIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEABODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-460-7440
Mailing Address - Street 1:62 ORLAND SQUARE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-6558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:62 ORLAND SQUARE DR STE 104
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-6558
Practice Address - Country:US
Practice Address - Phone:708-460-7440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0261301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty