Provider Demographics
NPI:1629252762
Name:1ST FAMILY DENTAL OF LOGAN SQUARE
Entity Type:Organization
Organization Name:1ST FAMILY DENTAL OF LOGAN SQUARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
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 1:2511 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3883
Mailing Address - Country:US
Mailing Address - Phone:773-772-5555
Mailing Address - Fax:773-772-5657
Practice Address - Street 1:2551 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2629
Practice Address - Country:US
Practice Address - Phone:773-728-5333
Practice Address - Fax:773-739-4300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023616122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty