Provider Demographics
NPI:1245822162
Name:KANKAKEE VALLEY ORAL MAXILLOFACIAL SURGERY PC
Entity type:Organization
Organization Name:KANKAKEE VALLEY ORAL MAXILLOFACIAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:INEKE
Authorized Official - Middle Name:CATHERINE
Authorized Official - Last Name:BASILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-933-0990
Mailing Address - Street 1:31 BRIARCLIFF PROFESSIONAL CTR.
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914
Mailing Address - Country:US
Mailing Address - Phone:815-933-0990
Mailing Address - Fax:815-933-0990
Practice Address - Street 1:31 BRIARCLIFF PROFESSIONAL CTR.
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914
Practice Address - Country:US
Practice Address - Phone:815-933-0990
Practice Address - Fax:815-933-0990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty