Provider Demographics
NPI:1346739372
Name:DANA E. FENDER, D.M.D., P.C.
Entity type:Organization
Organization Name:DANA E. FENDER, D.M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:E
Authorized Official - Last Name:FENDER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-356-2222
Mailing Address - Street 1:PO BOX 674467
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-4467
Mailing Address - Country:US
Mailing Address - Phone:217-356-2222
Mailing Address - Fax:
Practice Address - Street 1:1715 BROADMOOR DR STE A
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-5984
Practice Address - Country:US
Practice Address - Phone:217-356-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-04
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19.0310541223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty