Provider Demographics
NPI:1528216538
Name:RAVENSWOOD DENTAL GROUP
Entity Type:Organization
Organization Name:RAVENSWOOD DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOTSOF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-334-3555
Mailing Address - Street 1:5015 N PAULINA ST
Mailing Address - Street 2:SUITE 330
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2756
Mailing Address - Country:US
Mailing Address - Phone:773-334-3555
Mailing Address - Fax:773-334-5771
Practice Address - Street 1:5015 N PAULINA ST
Practice Address - Street 2:SUITE 330
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2756
Practice Address - Country:US
Practice Address - Phone:773-334-3555
Practice Address - Fax:773-334-5771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019019228122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty