Provider Demographics
NPI:1629347497
Name:FAIRFIELD DENTAL
Entity Type:Organization
Organization Name:FAIRFIELD DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOROVILAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-740-4100
Mailing Address - Street 1:3607 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5605
Mailing Address - Country:US
Mailing Address - Phone:773-588-7660
Mailing Address - Fax:
Practice Address - Street 1:732 N FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-8160
Practice Address - Country:US
Practice Address - Phone:847-740-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAWRENCE DENTAL GROUP, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023746122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty