1679966972 NPI number — MAX ROSENSTOCK EMMERLING DDS, MD

Table of content: MAX ROSENSTOCK EMMERLING DDS, MD (NPI 1679966972)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679966972 NPI number — MAX ROSENSTOCK EMMERLING DDS, MD

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
EMMERLING

Provider First Name:
MAX

Provider Middle Name:
ROSENSTOCK

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
DDS, MD

Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679966972

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
08/24/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 W HARRISON ST

Provider Second Line Business Mailing Address:
CLINIC D, ORAL MAXILLOFACIAL SURGERY

Provider Business Mailing Address City Name:
CHICAGO

Provider Business Mailing Address State Name:
IL

Provider Business Mailing Address Postal Code:
60612-3714

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
312-864-5159

Provider Business Mailing Address Fax Number:
312-864-9827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1969 W OGDEN AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
CHICAGO

Provider Business Practice Location Address State Name:
IL

Provider Business Practice Location Address Postal Code:
60612-3765

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
312-864-0200

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
03/10/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 204E00000X , with the licence number: 036.156717 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .