Provider Demographics
NPI:1225108665
Name:RUSSELL J BAK DDS PC
Entity Type:Organization
Organization Name:RUSSELL J BAK DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-759-4191
Mailing Address - Street 1:433 N BOLINGBROOK DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440
Mailing Address - Country:US
Mailing Address - Phone:630-759-4191
Mailing Address - Fax:630-759-4378
Practice Address - Street 1:433 N BOLINGBROOK DR
Practice Address - Street 2:SUITE 1
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440
Practice Address - Country:US
Practice Address - Phone:630-759-4191
Practice Address - Fax:630-759-4378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-0249121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty