1699868364 NPI number — CHICAGO OSTEOPATHIC HOSPITAL DENTAL CLINIC, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699868364 NPI number — CHICAGO OSTEOPATHIC HOSPITAL DENTAL CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHICAGO OSTEOPATHIC HOSPITAL DENTAL CLINIC, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1699868364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1525 E. 53RD ST.
Provider Second Line Business Mailing Address:
#522
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60615-4530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-947-4665
Provider Business Mailing Address Fax Number:
773-256-2373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1525 E. 53RD ST.
Provider Second Line Business Practice Location Address:
#522
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60615-4530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-947-4665
Provider Business Practice Location Address Fax Number:
773-256-2373
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
ANA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
773-947-4665

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  019022626 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 101659 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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