Provider Demographics
NPI:1275914848
Name:SCOTT OVERHOLSER, DDS P.C.
Entity Type:Organization
Organization Name:SCOTT OVERHOLSER, DDS P.C.
Other - Org Name:LAKEVIEW DENTAL ARTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:OVERHOLSER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-270-5000
Mailing Address - Street 1:3115 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657
Mailing Address - Country:US
Mailing Address - Phone:773-270-5000
Mailing Address - Fax:872-206-5337
Practice Address - Street 1:3115 N BROADWAY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:773-270-5000
Practice Address - Fax:872-206-5337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190262601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty