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
State | License ID | Taxonomies |
---|---|---|
IL | 019019228 | 122300000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122300000X | Dental Providers | Dentist | Group - Single Specialty |