Provider Demographics
NPI:1508038027
Name:LOGAN SQUARE DENTAL SERVICE CENTER
Entity Type:Organization
Organization Name:LOGAN SQUARE DENTAL SERVICE CENTER
Other - Org Name:CICERO IRVING PARK DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-284-0410
Mailing Address - Street 1:3946 N CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2711
Mailing Address - Country:US
Mailing Address - Phone:773-283-4838
Mailing Address - Fax:773-283-4389
Practice Address - Street 1:3946 N CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2711
Practice Address - Country:US
Practice Address - Phone:773-283-4838
Practice Address - Fax:773-283-4389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental