Provider Demographics
NPI:1245741768
Name:UDELSON ELMHURST LLC
Entity Type:Organization
Organization Name:UDELSON ELMHURST LLC
Other - Org Name:ELMHURST DENTISTRY FOR KIDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:UDELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-833-1166
Mailing Address - Street 1:311 N YORK ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2317
Mailing Address - Country:US
Mailing Address - Phone:630-833-1166
Mailing Address - Fax:
Practice Address - Street 1:311 N YORK ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2317
Practice Address - Country:US
Practice Address - Phone:630-833-1166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021001495261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL021001495OtherPEDIATRIC DENTISTRY