Provider Demographics
NPI:1578752044
Name:DR PAUL RUSSELL A NICOTRA DDS LTD
Entity Type:Organization
Organization Name:DR PAUL RUSSELL A NICOTRA DDS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R A
Authorized Official - Last Name:NICOTRA
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-358-4700
Mailing Address - Street 1:135 W JOHNSON ST
Mailing Address - Street 2:STE #3
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067
Mailing Address - Country:US
Mailing Address - Phone:847-358-4700
Mailing Address - Fax:847-358-8625
Practice Address - Street 1:135 W JOHNSON ST
Practice Address - Street 2:STE #3
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067
Practice Address - Country:US
Practice Address - Phone:847-358-4700
Practice Address - Fax:847-358-8625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019130821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty