Provider Demographics
NPI:1447388764
Name:COUCH, CLARISSA (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLARISSA
Middle Name:
Last Name:COUCH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3741
Mailing Address - Country:US
Mailing Address - Phone:312-572-4788
Mailing Address - Fax:
Practice Address - Street 1:10220 S 76TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:BRIDGEVIEW
Practice Address - State:IL
Practice Address - Zip Code:60455-2425
Practice Address - Country:US
Practice Address - Phone:708-974-6160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190228171223D0001X
IL019-022817122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101942OtherTIN