Provider Demographics
NPI:1699942722
Name:MAIN DENTAL ASSOCIATES, LTD.
Entity type:Organization
Organization Name:MAIN DENTAL ASSOCIATES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-966-1700
Mailing Address - Street 1:6457 DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2604
Mailing Address - Country:US
Mailing Address - Phone:847-966-1700
Mailing Address - Fax:847-966-1785
Practice Address - Street 1:6457 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2604
Practice Address - Country:US
Practice Address - Phone:847-966-1700
Practice Address - Fax:847-966-1785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-014182261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental