Provider Demographics
NPI:1659582062
Name:ORAL FACIAL & IMPLANT SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:ORAL FACIAL & IMPLANT SPECIALISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:ZIDRON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-381-0106
Mailing Address - Street 1:21660 W FIELD PKWY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DEER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60010-7265
Mailing Address - Country:US
Mailing Address - Phone:847-381-0106
Mailing Address - Fax:847-381-0265
Practice Address - Street 1:21660 W FIELD PKWY
Practice Address - Street 2:SUITE 220
Practice Address - City:DEER PARK
Practice Address - State:IL
Practice Address - Zip Code:60010-7265
Practice Address - Country:US
Practice Address - Phone:847-381-0106
Practice Address - Fax:847-381-0265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0600018241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty