Provider Demographics
NPI:1679788319
Name:YOURTHODONTIST LIMITED
Entity Type:Organization
Organization Name:YOURTHODONTIST LIMITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MEENAKSHI
Authorized Official - Middle Name:
Authorized Official - Last Name:BALAKRISHNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:630-515-2727
Mailing Address - Street 1:195 NORTH HARBOR DRIVE
Mailing Address - Street 2:#1304
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7528
Mailing Address - Country:US
Mailing Address - Phone:630-515-2727
Mailing Address - Fax:419-735-6033
Practice Address - Street 1:1330 OGDEN AVENUE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2772
Practice Address - Country:US
Practice Address - Phone:630-515-2727
Practice Address - Fax:419-735-6033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty