Provider Demographics
NPI:1679972582
Name:MD YORKVILLE LLC
Entity type:Organization
Organization Name:MD YORKVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:MITRA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-553-2505
Mailing Address - Street 1:728 E. VETERANS PARKWAY
Mailing Address - Street 2:SUITE 113
Mailing Address - City:YORKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60560
Mailing Address - Country:US
Mailing Address - Phone:630-553-2505
Mailing Address - Fax:
Practice Address - Street 1:728 E. VETERANS PARKWAY
Practice Address - Street 2:SUITE 113
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560
Practice Address - Country:US
Practice Address - Phone:630-553-2505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190273191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty