Provider Demographics
NPI:1437175833
Name:SOURIS, CHRISTA MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTA
Middle Name:MARIE
Last Name:SOURIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 S LAKE SHORE DR
Mailing Address - Street 2:APT #3414
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-3282
Mailing Address - Country:US
Mailing Address - Phone:773-955-7889
Mailing Address - Fax:773-955-7889
Practice Address - Street 1:5050 S LAKE SHORE DR
Practice Address - Street 2:APT #3414
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-3282
Practice Address - Country:US
Practice Address - Phone:773-955-7889
Practice Address - Fax:773-955-7889
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5977015122300000X
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist