Active NPI
Kelly Anne Mack, RD4
- Dental Hygienist
- Wheaton, IL
National Provider Identifier
1245308899
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dental Hygienist
- Practice address
- 55 E Loop Rd
Grove Dental Assoc Suite 201
Wheaton, IL 60187 - Phone
- (630) 653-8899
- NPI assigned
- Dec 1, 2006
- Sex
- Female
- Sole proprietor
- No
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 |
|---|---|---|---|---|
| Dental Hygienist | 124Q00000X | IL | Primary |
Addresses
Primary practice location
55 E Loop Rd
Grove Dental Assoc Suite 201
Wheaton, IL 60187
Mailing address
621 Glacier Trail
Roselle, IL 60172
Phone (630) 980-0992
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 |
|---|---|---|---|
| 020008841 | IL | MD | Dental Hygienist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Professional Dental Alliance of Illinois Ortho PLLC | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Dental Clinic/Center
- Bolingbrook, IL
- NPI 1457987901
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1164931200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1245308899",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "621 GLACIER TRAIL",
"city": "ROSELLE",
"state": "IL",
"postal_code": "60172",
"telephone_number": "630-980-0992"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "55 E LOOP RD",
"address_2": "GROVE DENTAL ASSOC SUITE 201",
"city": "WHEATON",
"state": "IL",
"postal_code": "60187",
"telephone_number": "630-653-8899"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MACK",
"first_name": "KELLY",
"middle_name": "ANNE",
"name_prefix": "Mrs.",
"credential": "RD4",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-12-01",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "124Q00000X",
"taxonomy_group": "",
"desc": "Dental Hygienist",
"state": "IL",
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Wheaton, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.