Provider Demographics
NPI:1568838043
Name:WOODLAWN DENTAL GALLERY
Entity Type:Organization
Organization Name:WOODLAWN DENTAL GALLERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OGBONNA
Authorized Official - Middle Name:BANKOLE
Authorized Official - Last Name:BOWDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-793-1220
Mailing Address - Street 1:8544 S STONY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-2248
Mailing Address - Country:US
Mailing Address - Phone:773-221-0800
Mailing Address - Fax:773-221-0868
Practice Address - Street 1:1502 E 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-2921
Practice Address - Country:US
Practice Address - Phone:773-496-5138
Practice Address - Fax:773-496-5142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027749122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty