Provider Demographics
NPI:1659691467
Name:JENNY BARUCH DDS PC
Entity Type:Organization
Organization Name:JENNY BARUCH DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:KWON
Authorized Official - Last Name:BARUCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-477-2369
Mailing Address - Street 1:805 S MCHENRY AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7450
Mailing Address - Country:US
Mailing Address - Phone:815-477-2369
Mailing Address - Fax:
Practice Address - Street 1:805 S MCHENRY AVE
Practice Address - Street 2:STE 1
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7450
Practice Address - Country:US
Practice Address - Phone:815-477-2369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-03
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028247302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization