1669620902 NPI number — ORAL & MAXILLOFACIAL SURGERY OF CHICAGO 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 1669620902 NPI number — ORAL & MAXILLOFACIAL SURGERY OF CHICAGO P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORAL & MAXILLOFACIAL SURGERY OF CHICAGO 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:
1669620902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6305 W 95TH ST FL 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK LAWN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60453-2255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-425-4301
Provider Business Mailing Address Fax Number:
888-334-0111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 ORLAND SQUARE DR STE 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLAND PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60462-6550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-349-4000
Provider Business Practice Location Address Fax Number:
888-334-0111
Provider Enumeration Date:
08/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JAIN
Authorized Official First Name:
GUNJAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
708-425-4301

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  019027447 , 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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