Provider Demographics
NPI:1417528589
Name:JEFFERSON PARK FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:JEFFERSON PARK FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR-DECISION ONE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CORY
Authorized Official - Last Name:STITES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-869-5857
Mailing Address - Street 1:4452 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3302
Mailing Address - Country:US
Mailing Address - Phone:773-777-4800
Mailing Address - Fax:773-777-4918
Practice Address - Street 1:4452 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3302
Practice Address - Country:US
Practice Address - Phone:773-777-4800
Practice Address - Fax:773-777-4918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-08
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty