Provider Demographics
NPI:1114492576
Name:COUNTRY COURT DENTAL CARE
Entity Type:Organization
Organization Name:COUNTRY COURT DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BOZENA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-680-5141
Mailing Address - Street 1:1880 W WINCHESTER RD STE 113
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5321
Mailing Address - Country:US
Mailing Address - Phone:847-680-5141
Mailing Address - Fax:847-680-5181
Practice Address - Street 1:1880 W WINCHESTER RD STE 113
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5321
Practice Address - Country:US
Practice Address - Phone:847-680-5141
Practice Address - Fax:847-680-5181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty