Provider Demographics
NPI:1447584560
Name:T MARIE PC
Entity Type:Organization
Organization Name:T MARIE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-827-7874
Mailing Address - Street 1:8100 S LUELLA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1029 HOWARD ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3877
Practice Address - Country:US
Practice Address - Phone:847-491-0660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026504122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty