Provider Demographics
NPI:1467626044
Name:PULASKI DENTAL CENTER P.C
Entity Type:Organization
Organization Name:PULASKI DENTAL CENTER P.C
Other - Org Name:PULASKI DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-585-1980
Mailing Address - Street 1:5607 S. PULASKI ROAD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629
Mailing Address - Country:US
Mailing Address - Phone:773-585-1980
Mailing Address - Fax:773-585-1517
Practice Address - Street 1:5607 S. PULASKI ROAD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629
Practice Address - Country:US
Practice Address - Phone:773-585-1980
Practice Address - Fax:773-585-1517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19024765122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty