Provider Demographics
NPI:1437657582
Name:ORTHODONTIC EXPERTS
Entity Type:Organization
Organization Name:ORTHODONTIC EXPERTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANGER
Authorized Official - Prefix:
Authorized Official - First Name:MONIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:BZDAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-801-7171
Mailing Address - Street 1:1654 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2255
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1654 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2255
Practice Address - Country:US
Practice Address - Phone:312-767-2088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHODONTIC EXPERTS LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-24
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210024881223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019028280Medicaid