Provider Demographics
NPI:1205841996
Name:CHICAGO DENTAL PROFESSIONALS INC
Entity Type:Organization
Organization Name:CHICAGO DENTAL PROFESSIONALS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:773-528-2205
Mailing Address - Street 1:2340 N CLYBOURN
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:773-528-2205
Mailing Address - Fax:773-528-2216
Practice Address - Street 1:2340 N CLYBOURN
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-528-2205
Practice Address - Fax:773-528-2216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020453122300000X
IL019014591122300000X
IL019017259122300000X
IL0210004991223P0221X
IL0190285641223P0221X
IL0210008311223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty