Provider Demographics
NPI:1316321524
Name:MAIN STREET DENTISTRY LLC
Entity type:Organization
Organization Name:MAIN STREET DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ACIERNO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-339-3172
Mailing Address - Street 1:129 S. ROSELLE RD
Mailing Address - Street 2:STE. 102
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193
Mailing Address - Country:US
Mailing Address - Phone:630-339-3172
Mailing Address - Fax:847-891-6775
Practice Address - Street 1:801 MAIN STREET NW
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914
Practice Address - Country:US
Practice Address - Phone:815-932-3516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization