Provider Demographics
NPI:1558532861
Name:DENTAL PROFILE
Entity Type:Organization
Organization Name:DENTAL PROFILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MILAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RONCEVIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-516-0000
Mailing Address - Street 1:2556 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5216
Mailing Address - Country:US
Mailing Address - Phone:773-782-0014
Mailing Address - Fax:773-782-8298
Practice Address - Street 1:2556 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5216
Practice Address - Country:US
Practice Address - Phone:773-782-0014
Practice Address - Fax:773-782-8298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty