Provider Demographics
NPI:1104364769
Name:1ST FAMILY DENTAL OF PULASKI PC
Entity Type:Organization
Organization Name:1ST FAMILY DENTAL OF PULASKI PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:VESNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BELKIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-340-8318
Mailing Address - Street 1:4901 N KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5009
Mailing Address - Country:US
Mailing Address - Phone:773-340-8318
Mailing Address - Fax:
Practice Address - Street 1:4707 N PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-4312
Practice Address - Country:US
Practice Address - Phone:773-279-9977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023616122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty