Provider Demographics
NPI:1497958698
Name:FOUR SEASONS DENTAL STUDIO
Entity Type:Organization
Organization Name:FOUR SEASONS DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KIET
Authorized Official - Middle Name:H
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-334-9922
Mailing Address - Street 1:2472 W FOSTER AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-6962
Mailing Address - Country:US
Mailing Address - Phone:773-220-8381
Mailing Address - Fax:773-334-9928
Practice Address - Street 1:2472 W. FOSTER AVE.
Practice Address - Street 2:SUITE 101
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:773-220-8381
Practice Address - Fax:773-334-9928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty