Provider Demographics
NPI:1992978852
Name:MAXILLOFACIAL AND FACIAL AESTHETIC SURGERY
Entity type:Organization
Organization Name:MAXILLOFACIAL AND FACIAL AESTHETIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:HADDLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:630-232-9090
Mailing Address - Street 1:426 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2708
Mailing Address - Country:US
Mailing Address - Phone:630-232-9090
Mailing Address - Fax:630-232-9094
Practice Address - Street 1:426 S 3RD ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2708
Practice Address - Country:US
Practice Address - Phone:630-232-9090
Practice Address - Fax:630-232-9094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH98071Medicare UPIN