Provider Demographics
NPI:1528875762
Name:MCGOWAN FAMILY DENTAL
Entity type:Organization
Organization Name:MCGOWAN FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-846-6013
Mailing Address - Street 1:3250 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2729
Mailing Address - Country:US
Mailing Address - Phone:773-232-5383
Mailing Address - Fax:
Practice Address - Street 1:3250 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2729
Practice Address - Country:US
Practice Address - Phone:773-232-5383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCGOWAN FAMILY DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental