Provider Demographics
NPI:1962793943
Name:MOBILE DENTAL CARE OF ILLINOIS PC
Entity type:Organization
Organization Name:MOBILE DENTAL CARE OF ILLINOIS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:CAMARDA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:708-744-9188
Mailing Address - Street 1:10 S RIVERSIDE PLZ
Mailing Address - Street 2:19 EAST
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-3728
Mailing Address - Country:US
Mailing Address - Phone:773-329-4450
Mailing Address - Fax:773-329-4454
Practice Address - Street 1:3716 217TH ST
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-3703
Practice Address - Country:US
Practice Address - Phone:773-329-4450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty