Provider Demographics
NPI:1760665442
Name:COLLEGE SQUARE DENTAL
Entity type:Organization
Organization Name:COLLEGE SQUARE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:DERRICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-983-8700
Mailing Address - Street 1:6448 COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-3290
Mailing Address - Country:US
Mailing Address - Phone:630-983-8700
Mailing Address - Fax:
Practice Address - Street 1:6448 COLLEGE RD
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-3290
Practice Address - Country:US
Practice Address - Phone:630-983-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0198141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty