Provider First Line Business Practice Location Address:
3115 N BROADWAY ST
Provider Second Line Business Practice Location Address:
LAKEVIEW DENTAL ARTS
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60657-4522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-270-5000
Provider Business Practice Location Address Fax Number:
872-206-5337
Provider Enumeration Date:
05/16/2008