Provider Demographics
NPI:1477664332
Name:NORTH SUBURBAN ORAL AND MAXILLOFACIAL SURGERY LTD
Entity Type:Organization
Organization Name:NORTH SUBURBAN ORAL AND MAXILLOFACIAL SURGERY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:MARTINO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-234-3390
Mailing Address - Street 1:900 N WESTMORELAND RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1674
Mailing Address - Country:US
Mailing Address - Phone:847-234-3390
Mailing Address - Fax:847-234-3391
Practice Address - Street 1:900 N WESTMORELAND RD
Practice Address - Street 2:SUITE 208
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1674
Practice Address - Country:US
Practice Address - Phone:847-234-3390
Practice Address - Fax:847-234-3391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210005371223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL524480Medicare ID - Type Unspecified