Organization
GREAT LAKES DENTAL P.C.
Active
Other names
Great Lakes Dental Solutions
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ANSHUMAN SONI DDS (PRESIDENT / DENTIST)
(815) 209-6272
Entity
Organization
Contact information
Practice address
1418 S MILWAUKEE AVE, SUITE 4, LIBERTYVILLE, IL 60048-3796
(815) 209-6272
Mailing address
1418 S MILWAUKEE AVE, SUITE 4, LIBERTYVILLE, IL 60048-3796
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
019026289
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1265415244
NPI 1
IL
05
—
9176879
—
IL
Enumeration date
11/23/2014
Last updated
12/16/2014
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