Provider First Line Business Practice Location Address:
2413 S STATE ST
Provider Second Line Business Practice Location Address:
IDEAL DENTAL CENTER
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60616-2311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-528-1800
Provider Business Practice Location Address Fax Number:
312-528-1881
Provider Enumeration Date:
10/19/2005