Provider Demographics
NPI:1558401844
Name:MONTROSE FAMILY DENTAL CENTER
Entity Type:Organization
Organization Name:MONTROSE FAMILY DENTAL CENTER
Other - Org Name:EDWARD G. VIVIT, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:VIVIT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-478-9393
Mailing Address - Street 1:3338 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1247
Mailing Address - Country:US
Mailing Address - Phone:773-478-9393
Mailing Address - Fax:773-478-9303
Practice Address - Street 1:3338 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1247
Practice Address - Country:US
Practice Address - Phone:773-478-9393
Practice Address - Fax:773-478-9303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022192122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty