Provider Demographics
NPI:1114261427
Name:BRYAN R. CICHON DDS PC
Entity Type:Organization
Organization Name:BRYAN R. CICHON DDS PC
Other - Org Name:RANDALL RIDGE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CICHON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-587-2600
Mailing Address - Street 1:700 S. RANDALL RD.
Mailing Address - Street 2:SUITE #1
Mailing Address - City:ST. CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174
Mailing Address - Country:US
Mailing Address - Phone:630-587-2600
Mailing Address - Fax:630-587-2605
Practice Address - Street 1:700 S. RANDALL RD.
Practice Address - Street 2:SUITE #1
Practice Address - City:ST. CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174
Practice Address - Country:US
Practice Address - Phone:630-587-2600
Practice Address - Fax:630-587-2605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-023433122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty