Provider First Line Business Practice Location Address:
1920 N LINCOLN AVE
Provider Second Line Business Practice Location Address:
STE #C7 MID AMERICA DENTAL CENTER
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60614-5480
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-642-5107
Provider Business Practice Location Address Fax Number:
312-642-2958
Provider Enumeration Date:
06/19/2007