Provider Demographics
NPI:1275833394
Name:CELESTE L MEDYNSKYJ, DDS LTD
Entity Type:Organization
Organization Name:CELESTE L MEDYNSKYJ, DDS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MEDYNSKYJ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-453-0793
Mailing Address - Street 1:1830 N 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707
Mailing Address - Country:US
Mailing Address - Phone:708-453-0793
Mailing Address - Fax:
Practice Address - Street 1:1600 W DEMPSTER ST
Practice Address - Street 2:LL1
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-699-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027913122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1891921177Medicaid