Organization
MALTA FAMILY DENTAL LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. ANNE ELIZABETH ANDERSON (OFFICE MANAGER)
(815) 825-5025
Entity
Organization
Contact information
Practice address
304 VAN BUREN ST, MALTA, IL 60150-9512
(815) 825-5025
(815) 516-0205
Mailing address
304 VAN BUREN ST, MALTA, IL 60150-9512
(815) 825-5025
(815) 516-0205
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
019027588
IL
124Q00000X
Dental Hygienist
020010952
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
019027588
—
IL
05
—
020010952
—
IL
Enumeration date
08/05/2011
Last updated
08/05/2011
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