Provider Demographics
NPI:1578246930
Name:BRISTLE DENTAL STUDIO
Entity Type:Organization
Organization Name:BRISTLE DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:224-612-1383
Mailing Address - Street 1:1700 N WESTERN AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5324
Mailing Address - Country:US
Mailing Address - Phone:312-620-7733
Mailing Address - Fax:
Practice Address - Street 1:1700 N WESTERN AVE UNIT A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5324
Practice Address - Country:US
Practice Address - Phone:312-620-7733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONNIE J. WOO, DMD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-10
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty