Provider Demographics
NPI:1467221010
Name:BRENT A ITO DMD MS PC
Entity Type:Organization
Organization Name:BRENT A ITO DMD MS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:ITO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:630-769-0707
Mailing Address - Street 1:7350 JANES AVE
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-2339
Mailing Address - Country:US
Mailing Address - Phone:630-769-0707
Mailing Address - Fax:
Practice Address - Street 1:7350 JANES AVE
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2339
Practice Address - Country:US
Practice Address - Phone:630-769-0707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental