Provider Demographics
NPI:1689960593
Name:JASON DIFANI, DDS, PC
Entity Type:Organization
Organization Name:JASON DIFANI, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:T
Authorized Official - Last Name:DIFANI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-824-8835
Mailing Address - Street 1:1843 W ROSCOE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1102
Mailing Address - Country:US
Mailing Address - Phone:309-824-8835
Mailing Address - Fax:
Practice Address - Street 1:5050 S KEDZIE AVE UNIT A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-3009
Practice Address - Country:US
Practice Address - Phone:773-778-2200
Practice Address - Fax:773-778-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027928122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty