Provider Demographics
NPI:1275933046
Name:RISORIUS DENTAL LLC
Entity Type:Organization
Organization Name:RISORIUS DENTAL LLC
Other - Org Name:RISORIUS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VLAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTEZATU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-965-9211
Mailing Address - Street 1:9211 WAUKEGAN RD
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2102
Mailing Address - Country:US
Mailing Address - Phone:847-965-9211
Mailing Address - Fax:847-583-9211
Practice Address - Street 1:9211 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2102
Practice Address - Country:US
Practice Address - Phone:847-965-9211
Practice Address - Fax:847-583-9211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028082122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty