Provider Demographics
NPI:1639267511
Name:ISAACSON, RICHARD D (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:D
Last Name:ISAACSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 N NORTHWEST HWY
Mailing Address - Street 2:STE 325
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:847-296-6100
Mailing Address - Fax:847-296-8706
Practice Address - Street 1:444 N NORTHWEST HWY
Practice Address - Street 2:STE 325
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-296-6100
Practice Address - Fax:847-296-8706
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19016864122300000X
IL0210011971223S0112X
IL1370000921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0080004915OtherBLUE CROSS GROUP
K17843Medicare ID - Type Unspecified
K17842Medicare ID - Type UnspecifiedMEMBER NUMBER
IL0080004915OtherBLUE CROSS GROUP