Provider Demographics
NPI:1235375593
Name:PATRICIA CRISOSTOMO DMD PC
Entity Type:Organization
Organization Name:PATRICIA CRISOSTOMO DMD PC
Other - Org Name:LAWRENCE-ASHLAND DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:BETTINA
Authorized Official - Last Name:CRISOSTOMO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:773-271-7910
Mailing Address - Street 1:P.O. BOX 408080
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-9998
Mailing Address - Country:US
Mailing Address - Phone:773-271-7910
Mailing Address - Fax:773-271-7912
Practice Address - Street 1:1732 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4412
Practice Address - Country:US
Practice Address - Phone:773-271-7910
Practice Address - Fax:773-271-7912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190251331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty