Provider Demographics
NPI:1851639835
Name:AIRLTE DENTAL OF ELGIN
Entity type:Organization
Organization Name:AIRLTE DENTAL OF ELGIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-214-1324
Mailing Address - Street 1:40 N AIRLITE ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4965
Mailing Address - Country:US
Mailing Address - Phone:847-214-1324
Mailing Address - Fax:847-214-1562
Practice Address - Street 1:40 N AIRLITE ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4965
Practice Address - Country:US
Practice Address - Phone:847-214-1324
Practice Address - Fax:847-214-1562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022943261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental