Provider Demographics
NPI:1073991162
Name:REZNIKOV DENTAL, PC
Entity Type:Organization
Organization Name:REZNIKOV DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
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 1:1556 S MICHIGAN AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605
Mailing Address - Country:US
Mailing Address - Phone:312-588-0043
Mailing Address - Fax:312-588-0287
Practice Address - Street 1:1556 S MICHIGAN AVE
Practice Address - Street 2:STE 110
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-1937
Practice Address - Country:US
Practice Address - Phone:312-588-0043
Practice Address - Fax:312-588-0287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029473122300000X
1223P0300X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty