Provider Demographics
NPI:1033284831
Name:PRAIRIE ORTHODONTICS PC
Entity Type:Organization
Organization Name:PRAIRIE ORTHODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:O
Authorized Official - Last Name:MUELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-249-8800
Mailing Address - Street 1:6121 WASHINGTON ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031
Mailing Address - Country:US
Mailing Address - Phone:847-249-8800
Mailing Address - Fax:847-249-8869
Practice Address - Street 1:6121 WASHINGTON ST
Practice Address - Street 2:SUITE 204
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031
Practice Address - Country:US
Practice Address - Phone:847-249-8800
Practice Address - Fax:847-249-8869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060064861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty