Provider Demographics
NPI:1659012920
Name:PORTAGE PARK DENTAL STUDIO
Entity Type:Organization
Organization Name:PORTAGE PARK DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-369-4076
Mailing Address - Street 1:1224 LAURA LN
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-5062
Mailing Address - Country:US
Mailing Address - Phone:708-369-4076
Mailing Address - Fax:
Practice Address - Street 1:5955 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2618
Practice Address - Country:US
Practice Address - Phone:773-481-9455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-02
Last Update Date:2022-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental