Provider Demographics
NPI:1578197026
Name:1ST FAMILY DENTAL OF WEST ROSELAND PC
Entity Type:Organization
Organization Name:1ST FAMILY DENTAL OF WEST ROSELAND PC
Other - Org Name:1ST FAMILY DENTAL OF WEST ROSELAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:VESNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BELKIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-433-4962
Mailing Address - Street 1:701 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-3902
Mailing Address - Country:US
Mailing Address - Phone:773-995-1234
Mailing Address - Fax:
Practice Address - Street 1:701 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-3902
Practice Address - Country:US
Practice Address - Phone:773-995-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty