Provider Demographics
NPI:1033281225
Name:PRAIRE SHORES DENTAL
Entity Type:Organization
Organization Name:PRAIRE SHORES DENTAL
Other - Org Name:MERCY DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-567-2299
Mailing Address - Street 1:2525 S MICHIGAN AVE
Mailing Address - Street 2:8TH FL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2333
Mailing Address - Country:US
Mailing Address - Phone:312-567-2299
Mailing Address - Fax:312-328-7954
Practice Address - Street 1:2525 S MICHIGAN AVE
Practice Address - Street 2:8TH FL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2333
Practice Address - Country:US
Practice Address - Phone:312-567-2299
Practice Address - Fax:312-328-7954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty