Provider Demographics
NPI:1669499505
Name:EVANSTON PERIODONTICS, LLC
Entity Type:Organization
Organization Name:EVANSTON PERIODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:NOUNEH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD; MS
Authorized Official - Phone:312-927-8882
Mailing Address - Street 1:636 CHURCH ST
Mailing Address - Street 2:SUITE # 722
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4508
Mailing Address - Country:US
Mailing Address - Phone:847-475-7754
Mailing Address - Fax:847-475-4725
Practice Address - Street 1:636 CHURCH ST
Practice Address - Street 2:SUITE # 722
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4508
Practice Address - Country:US
Practice Address - Phone:847-475-7754
Practice Address - Fax:847-475-4725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty