Basic Information
| Provider Information | |||||||||
| NPI: | 1306107578 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DECATUR 2012 LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 E ALGONQUIN RD | ||||||||
| Address2: | SUITE 610 | ||||||||
| City: | SCHAUMBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601734144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889888406 | ||||||||
| FaxNumber: | 8474967603 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 E PERSHING RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625263213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889884066 | ||||||||
| FaxNumber: | 8474967603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2012 | ||||||||
| LastUpdateDate: | 10/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | ALEXANDER | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING PAYER RELATIONS MGR | ||||||||
| AuthorizedOfficialTelephone: | 8474537396 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPCS | ||||||||
| NPICertificationDate: | 10/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.