Provider Demographics
NPI:1033465711
Name:NORTH CLARK DENTAL
Entity Type:Organization
Organization Name:NORTH CLARK DENTAL
Other - Org Name:DR VICTOR TOMASIAN DMD LTD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:W
Authorized Official - Last Name:TOMASIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:773-262-8393
Mailing Address - Street 1:6339 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660
Mailing Address - Country:US
Mailing Address - Phone:773-262-8393
Mailing Address - Fax:773-262-5896
Practice Address - Street 1:6339 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660
Practice Address - Country:US
Practice Address - Phone:773-262-8393
Practice Address - Fax:773-262-5896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022349305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization