Provider Demographics
NPI:1053665380
Name:LAKE ZURICH ORTHODONTICS LLC
Entity Type:Organization
Organization Name:LAKE ZURICH ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:CALABRESE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-847-7736
Mailing Address - Street 1:545 N. RAND RD.
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-3134
Mailing Address - Country:US
Mailing Address - Phone:847-847-7736
Mailing Address - Fax:866-302-4168
Practice Address - Street 1:545 N. RAND RD.
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-3134
Practice Address - Country:US
Practice Address - Phone:847-847-7736
Practice Address - Fax:866-302-4168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0024831223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty