Provider Demographics
NPI:1689765679
Name:WILLIS ABT DENTAL PRACTICE
Entity Type:Organization
Organization Name:WILLIS ABT DENTAL PRACTICE
Other - Org Name:PAUL WILLIS DDS ELLIOT ABT DDS MS RANDALL HIRSCH DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIOT
Authorized Official - Middle Name:
Authorized Official - Last Name:ABT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-177-2404
Mailing Address - Street 1:4709 GOLF ROAD
Mailing Address - Street 2:SUITE 1005 2 CONCOURSE OFFICE PLAZA
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076
Mailing Address - Country:US
Mailing Address - Phone:847-677-2404
Mailing Address - Fax:847-677-7432
Practice Address - Street 1:4709 GOLF ROAD
Practice Address - Street 2:SUITE 1005 2 CONCOURSE OFFICE PLAZA
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076
Practice Address - Country:US
Practice Address - Phone:847-677-2404
Practice Address - Fax:847-677-7432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty