Individual
BRENT DANIELSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1400 W 47TH ST, LA GRANGE, IL 60525-6141
(708) 482-4420
Mailing address
1400 W 47TH ST, LA GRANGE, IL 60525-6141
(708) 482-4420
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
019-015421
IL
Other
Enumeration date
03/29/2010
Last updated
03/29/2010
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