Provider Demographics
NPI:1467774661
Name:PARK RIDGE ENDODONTICS
Entity Type:Organization
Organization Name:PARK RIDGE ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:I
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-823-4161
Mailing Address - Street 1:350 S NORTHWEST HWY
Mailing Address - Street 2:SUITE 116
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4216
Mailing Address - Country:US
Mailing Address - Phone:847-823-4161
Mailing Address - Fax:847-823-4163
Practice Address - Street 1:350 S NORTHWEST HWY
Practice Address - Street 2:SUITE 116
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4216
Practice Address - Country:US
Practice Address - Phone:847-823-4161
Practice Address - Fax:847-823-4163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060009606302R00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization