Provider Demographics
NPI:1316411234
Name:VITAL DENTAL CARE INC
Entity type:Organization
Organization Name:VITAL DENTAL CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WASAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BALOCH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:708-529-0900
Mailing Address - Street 1:8908 MIDDLETON RD
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561-8441
Mailing Address - Country:US
Mailing Address - Phone:630-915-7863
Mailing Address - Fax:
Practice Address - Street 1:2835 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2702
Practice Address - Country:US
Practice Address - Phone:630-915-7863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-14
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019030247Medicaid