Provider Demographics
NPI:1326498130
Name:CHICAGOLAND IMPLANT SPECIALIST LTD
Entity Type:Organization
Organization Name:CHICAGOLAND IMPLANT SPECIALIST LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETRUNGARO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-415-7481
Mailing Address - Street 1:6420 N LEHIGH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-2704
Mailing Address - Country:US
Mailing Address - Phone:312-624-9300
Mailing Address - Fax:
Practice Address - Street 1:237 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-2647
Practice Address - Country:US
Practice Address - Phone:312-533-8489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210014011223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty