Provider Demographics
NPI:1235209727
Name:F L M DENTAL CORP PC
Entity Type:Organization
Organization Name:F L M DENTAL CORP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARISCAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-929-4140
Mailing Address - Street 1:3514 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1104
Mailing Address - Country:US
Mailing Address - Phone:773-929-4140
Mailing Address - Fax:773-929-2514
Practice Address - Street 1:3514 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-1104
Practice Address - Country:US
Practice Address - Phone:773-929-4140
Practice Address - Fax:773-929-2514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190201121223G0001X
IL0190270201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty