Active NPI
Brent Danielson, DDS
- General Practice Dentistry
- La Grange, IL
National Provider Identifier
1174848576
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 019-015421
- Practice address
- 1400 W 47TH St
La Grange, IL 60525-6141 - Phone
- (708) 482-4420
- NPI assigned
- Mar 29, 2010
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 019-015421 | IL | Primary |
Addresses
Primary practice location
1400 W 47TH St
La Grange, IL 60525-6141
Mailing address
1400 W 47TH St
La Grange, IL 60525-6141
Phone (708) 482-4420
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019-015421 | IL | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1269820800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1269820800000",
"number": "1174848576",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1400 W 47TH ST",
"city": "LA GRANGE",
"state": "IL",
"postal_code": "605256141",
"telephone_number": "708-482-4420"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1400 W 47TH ST",
"city": "LA GRANGE",
"state": "IL",
"postal_code": "605256141",
"telephone_number": "708-482-4420"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DANIELSON",
"first_name": "BRENT",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2010-03-29",
"last_updated": "2010-03-29",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "IL",
"license": "019-015421",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in La Grange, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 29, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.