Provider Demographics
NPI:1144633314
Name:PALOS FAMILY DENTAL LLC
Entity type:Organization
Organization Name:PALOS FAMILY DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:H
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-448-4161
Mailing Address - Street 1:7132 W 127TH ST
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1560
Mailing Address - Country:US
Mailing Address - Phone:708-448-4161
Mailing Address - Fax:708-448-4326
Practice Address - Street 1:7132 W 127TH ST
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1560
Practice Address - Country:US
Practice Address - Phone:708-448-4161
Practice Address - Fax:708-448-4326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0286161223G0001X
IL019-0171781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty