Provider Demographics
NPI:1497842132
Name:BARACK, DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BARACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 OLD ORCHARD SHOPPING CTR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1425
Mailing Address - Country:US
Mailing Address - Phone:847-982-0640
Mailing Address - Fax:
Practice Address - Street 1:4905 OLD ORCHARD SHOPPING CTR
Practice Address - Street 2:SUITE 310
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1425
Practice Address - Country:US
Practice Address - Phone:847-982-0640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021-0012021223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics