| Organization Name: | ANDRIS FAMILY DENTAL, LLC |
| NPI Number: | 1225493034 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RYAN WAYNE ANDRIS (DENTIST/OWNER) |
| Mailing Address: | 636 W Jefferson St Morton |
| State: | IL US |
| Postal Code: | 615501581 |
| Phone Number: | 3092638317 |
| Fax Number: | 3092632175 |
| NPI Enumeration Date: | 12/21/2015 |
| NPI Last Update Date: | 12/21/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | 019.029393 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |