# SUBURBAN FAMILY DENTAL

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1295978104
- **Authorized official:** MARY MILLER (OFFICE MANAGER)
- **Authorized official phone:** (847) 640-0778

## Contact information

- **Practice address:** 645 W GOLF RD, DES PLAINES, IL 60016-2462
- **Practice address phone:** (847) 640-0778
- **Practice address fax:** (847) 640-2599
- **Mailing address:** 645 WEST GOLF ROAD, DES PLAINES, IL 60016
- **Mailing address phone:** (847) 640-0778
- **Mailing address fax:** (847) 640-2599

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 019016362 | IL | — |
| 1223G0001X | General Practice Dentistry | 019022514 | IL | — |
| 1223P0300X | Periodontics | 019022485 | IL | — |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 019016834 | IL | Yes |

## Other

- **Enumeration date:** 04/08/2009
- **Last updated:** 04/08/2009