Provider Demographics
NPI:1285025213
Name:LAWRENCE PLAZA DENTAL LLC
Entity Type:Organization
Organization Name:LAWRENCE PLAZA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ACIERNO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-339-3172
Mailing Address - Street 1:5912 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:129 S ROSELLE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60193-5540
Practice Address - Country:US
Practice Address - Phone:630-339-3172
Practice Address - Fax:847-339-3172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01905148305R00000X
IL019027347305R00000X
IL019018205305R00000X
IL019016834305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization