Llcdental,

Primary specialty

DentistTaxonomy code 122300000X

License

019020348 Issued in IL

Legal business name

LLCDENTAL,

Practice address

3494 Vollmer Rd
Olympia Fields, IL 60461-1018

Phone

(708) 747-2273

Fax

(708) 747-2238

NPI assigned

Nov 3, 2016

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Kevin Dale Mimms, M.S.

Title

Manager

Phone

(708) 747-2273

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1478131200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1478131200000",
    "number": "1669924833",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3494 VOLLMER RD",
            "city": "OLYMPIA FIELDS",
            "state": "IL",
            "postal_code": "604611018",
            "telephone_number": "708-747-2273",
            "fax_number": "708-747-2238"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3494 VOLLMER RD",
            "city": "OLYMPIA FIELDS",
            "state": "IL",
            "postal_code": "604611018",
            "telephone_number": "708-747-2273",
            "fax_number": "708-747-2238"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LLCDENTAL,",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-11-03",
        "last_updated": "2016-11-03",
        "status": "A",
        "authorized_official_last_name": "MIMMS",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_middle_name": "DALE",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "708-747-2273",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "M.S."
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": "IL",
            "license": "019020348",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Dentist in Olympia Fields, IL
• Providers in Olympia Fields, IL by specialty
• Dentist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 3, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.