Provider Demographics
NPI:1417384793
Name:GRIFFIN ORTHODONTICS PC
Entity Type:Organization
Organization Name:GRIFFIN ORTHODONTICS PC
Other - Org Name:IVORY DENTAL SPECIALIST LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BONCIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-239-7696
Mailing Address - Street 1:1040 E 47TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-3600
Mailing Address - Country:US
Mailing Address - Phone:773-924-5123
Mailing Address - Fax:
Practice Address - Street 1:1040 E 47TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653
Practice Address - Country:US
Practice Address - Phone:773-239-7696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVORY DENTAL SPECIALIST LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190257261223X0400X
IL0210023611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty