Provider Demographics
NPI:1033381090
Name:BRICKYARD DENTAL CENTER
Entity Type:Organization
Organization Name:BRICKYARD DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOS
Authorized Official - Middle Name:A
Authorized Official - Last Name:TSALIAGOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-237-0707
Mailing Address - Street 1:6020 W DIVERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1108
Mailing Address - Country:US
Mailing Address - Phone:773-237-0707
Mailing Address - Fax:773-622-6191
Practice Address - Street 1:6020 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1108
Practice Address - Country:US
Practice Address - Phone:773-237-0707
Practice Address - Fax:773-622-6191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty