Provider Demographics
NPI:1073676946
Name:ASSOCIATED DENTAL CENTER
Entity Type:Organization
Organization Name:ASSOCIATED DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:773-874-0404
Mailing Address - Street 1:PO BOX 19329
Mailing Address - Street 2:747 E 79TH STREET
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619
Mailing Address - Country:US
Mailing Address - Phone:773-874-0404
Mailing Address - Fax:773-874-5900
Practice Address - Street 1:747 E 79TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619
Practice Address - Country:US
Practice Address - Phone:773-874-0404
Practice Address - Fax:773-874-5900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020907122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty