Provider Demographics
NPI:1558507939
Name:BERWYN FAMILY DENTAL CENTER, INC
Entity Type:Organization
Organization Name:BERWYN FAMILY DENTAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-363-4379
Mailing Address - Street 1:7001 W OGDEN AVENUE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3652
Mailing Address - Country:US
Mailing Address - Phone:708-749-2419
Mailing Address - Fax:708-749-2429
Practice Address - Street 1:7001 W OGDEN AVENUE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3652
Practice Address - Country:US
Practice Address - Phone:708-749-2419
Practice Address - Fax:708-749-2429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-022522261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental