1386341857 NPI number — EAST VILLAGE DENTAL CENTRE PLLC

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 1386341857 NPI number — EAST VILLAGE DENTAL CENTRE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST VILLAGE DENTAL CENTRE PLLC
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:
1386341857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 N ASHLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60622-5111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-341-9325
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 N ASHLAND 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:
60622-5111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-341-9325
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2023

Additional Information

Authorized Official

Authorized Official Last Name:
COLE
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
VP INSURANCE PLAN MANAGEMENT
Authorized Official Telephone Number:
727-424-2990

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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