1205288982 NPI number — LAKESIDE ORAL & FACIAL SURGERY INSTITUTE

Table of content: (NPI 1205288982)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205288982 NPI number — LAKESIDE ORAL & FACIAL SURGERY INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE ORAL & FACIAL SURGERY INSTITUTE
Provider Last Name:
Provider First Name:
Provider Middle Name:
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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:
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Provider Other Name Prefix Text:
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NPI Number Information

NPI Number:
1205288982
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 RIDGE AVE
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60201-2455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-328-8899
Provider Business Mailing Address Fax Number:
847-563-1350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 RIDGE AVE
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60201-2455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-328-8899
Provider Business Practice Location Address Fax Number:
847-563-1350
Provider Enumeration Date:
07/06/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HARVEY
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
Authorized Official Title or Position:
ORAL & MAXILLOFACIAL SURGEON
Authorized Official Telephone Number:
847-328-8899

Provider Taxonomy Codes

  • Taxonomy code: 261QS0112X , with the licence number:  021002718 , 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)





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