Provider Demographics
NPI:1003085465
Name:LAKE COOK DENTAL CENTER P C
Entity Type:Organization
Organization Name:LAKE COOK DENTAL CENTER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSANNA
Authorized Official - Middle Name:MIRANDA
Authorized Official - Last Name:LESNIAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-955-2331
Mailing Address - Street 1:1207 MCHENRY RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1371
Mailing Address - Country:US
Mailing Address - Phone:847-955-2331
Mailing Address - Fax:
Practice Address - Street 1:1207 MCHENRY ROAD
Practice Address - Street 2:SUITE 215
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-1371
Practice Address - Country:US
Practice Address - Phone:847-955-2331
Practice Address - Fax:847-955-2332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025184261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6607960001Medicare NSC