| NPI | 1114178183 |
|---|---|
| Doing Business As | PROVIDENCE FAMILY DENTAL |
| Entity Type | Organization |
| Authorized Contact | SIRI CHANTHASALO President 847-217-7215 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: IL 019.025831) |
| Enumeration Date | 2008-10-08 |
| Last Update Date | 2008-10-08 |