Organization
DECATUR 2012 LLC
Active
Other names
Family Dental
Organization subpart
No
Provider details
NPI number
Authorized official
MR. BRANDON ALEXANDER TAYLOR CPCS (CREDENTIALING PAYER RELATIONS MGR)
(847) 453-7396
Entity
Organization
Contact information
Practice address
141 E PERSHING RD, DECATUR, IL 62526-3213
(888) 988-4066
(847) 496-7603
Mailing address
2050 E ALGONQUIN RD, SUITE 610, SCHAUMBURG, IL 60173-4144
(888) 988-8406
(847) 496-7603
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Enumeration date
06/05/2012
Last updated
10/15/2021
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