Provider Demographics
NPI:1033386107
Name:DREW MANSON
Entity Type:Organization
Organization Name:DREW MANSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-685-3933
Mailing Address - Street 1:3936 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-2732
Mailing Address - Country:US
Mailing Address - Phone:773-685-3933
Mailing Address - Fax:
Practice Address - Street 1:3936 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2732
Practice Address - Country:US
Practice Address - Phone:773-685-3933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019017059261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental