Provider Demographics
NPI:1386217164
Name:RIVERSIDE DENTAL INVESTMENTS LLC
Entity type:Organization
Organization Name:RIVERSIDE DENTAL INVESTMENTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-765-9900
Mailing Address - Street 1:13510 JULIE DR
Mailing Address - Street 2:
Mailing Address - City:POPLAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:61065-7829
Mailing Address - Country:US
Mailing Address - Phone:815-765-9900
Mailing Address - Fax:815-765-9901
Practice Address - Street 1:13510 JULIE DR
Practice Address - Street 2:
Practice Address - City:POPLAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:61065-7829
Practice Address - Country:US
Practice Address - Phone:815-765-9900
Practice Address - Fax:815-765-9901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1134353014OtherINDIVIDUAL NPI
IL1356461255OtherINDIVIDUAL NPI