Provider Demographics
NPI:1144643966
Name:WOODSTOCK DENTAL ASSOCIATES, LTD.
Entity type:Organization
Organization Name:WOODSTOCK DENTAL ASSOCIATES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUNGYOON
Authorized Official - Middle Name:
Authorized Official - Last Name:HA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-338-1138
Mailing Address - Street 1:666 W JACKSON ST STE B
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3198
Mailing Address - Country:US
Mailing Address - Phone:815-338-1138
Mailing Address - Fax:815-338-3910
Practice Address - Street 1:666 W JACKSON ST STE B
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3198
Practice Address - Country:US
Practice Address - Phone:815-338-1138
Practice Address - Fax:815-338-3910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025426302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization