| Organization Name: | PRAIRIE VALLEY DENTAL, P.C. |
| NPI Number: | 1346433000 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | KEVIN MICHAEL ENBERG (PRESIDENT) |
| Mailing Address: | 108 Valley Dr Unit H Elburn |
| State: | IL US |
| Postal Code: | 601198872 |
| Phone Number: | 6303651675 |
| Fax Number: | 6303651678 |
| NPI Enumeration Date: | 08/24/2007 |
| NPI Last Update Date: | 08/24/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |