Provider Demographics
NPI:1427580075
Name:ATHENA DENTAL INSTITUTE P C
Entity Type:Organization
Organization Name:ATHENA DENTAL INSTITUTE P C
Other - Org Name:ATHENA DENTAL GROUP OF CHICAGO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER-FINCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-235-2000
Mailing Address - Street 1:1621 W NORTH AVE
Mailing Address - Street 2:UNIT C-1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2328
Mailing Address - Country:US
Mailing Address - Phone:773-235-2000
Mailing Address - Fax:
Practice Address - Street 1:1621 W NORTH AVE
Practice Address - Street 2:UNIT C-1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2328
Practice Address - Country:US
Practice Address - Phone:773-235-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190220591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1002966Medicaid