Provider Demographics
NPI:1386981371
Name:ALPHA DENTAL CARE
Entity type:Organization
Organization Name:ALPHA DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS RECEPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-223-5839
Mailing Address - Street 1:4105 FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1115
Mailing Address - Country:US
Mailing Address - Phone:815-223-5839
Mailing Address - Fax:815-223-0957
Practice Address - Street 1:4105 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1115
Practice Address - Country:US
Practice Address - Phone:815-223-5839
Practice Address - Fax:815-223-0957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-022454122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty