Provider Demographics
NPI:1053976605
Name:DENTAL ASSOCIATES OF ORLAND PARK, PLLC
Entity type:Organization
Organization Name:DENTAL ASSOCIATES OF ORLAND PARK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER CREDENTIALING TEAM LEADER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-808-3031
Mailing Address - Street 1:11711 W BURLEIGH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9443 W 144TH PL
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2543
Practice Address - Country:US
Practice Address - Phone:708-403-9848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-08
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty