Provider Demographics
NPI:1447568977
Name:PANOS DENTISTRY CENTER INC.
Entity Type:Organization
Organization Name:PANOS DENTISTRY CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN ASSISTANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:PELLETIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-577-2100
Mailing Address - Street 1:4849 N. MILWAUKEE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2171
Mailing Address - Country:US
Mailing Address - Phone:773-577-2100
Mailing Address - Fax:
Practice Address - Street 1:4849 N. MILWAUKEE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2171
Practice Address - Country:US
Practice Address - Phone:773-577-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0203971223G0001X
IL021-0005471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1104979533OtherNATIONAL PROVIDER NUMBER