Provider Demographics
NPI:1043750714
Name:BLOOMINGDALE DENTAL REZ, PC
Entity Type:Organization
Organization Name:BLOOMINGDALE DENTAL REZ, PC
Other - Org Name:MINALT & WOJCICKI DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:REZNIKOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-877-3570
Mailing Address - Street 1:1 TIFFANY PT STE 209
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2916
Mailing Address - Country:US
Mailing Address - Phone:630-671-0700
Mailing Address - Fax:630-671-0546
Practice Address - Street 1:1 TIFFANY PT STE 209
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2916
Practice Address - Country:US
Practice Address - Phone:630-671-0700
Practice Address - Fax:630-671-0546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029473122300000X
IL0190238981223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty