Provider Demographics
NPI:1174651459
Name:NORTHSHORE METROPOLITAN DENTAL ASSOCIATES INC
Entity Type:Organization
Organization Name:NORTHSHORE METROPOLITAN DENTAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:KA-TAI
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-673-6770
Mailing Address - Street 1:1790 NATIONS DR
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-9164
Mailing Address - Country:US
Mailing Address - Phone:847-336-4880
Mailing Address - Fax:
Practice Address - Street 1:1790 NATIONS DR
Practice Address - Street 2:SUITE 212
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-9164
Practice Address - Country:US
Practice Address - Phone:847-336-4880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190251541223G0001X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty