Provider Demographics
NPI: | 1700207594 |
---|---|
Name: | INNOVATIVE ORTHODONTICS |
Entity Type: | Organization |
Organization Name: | INNOVATIVE ORTHODONTICS |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | TREASURER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | JOHN |
Authorized Official - Middle Name: | ALVAN |
Authorized Official - Last Name: | GORDON |
Authorized Official - Suffix: | JR |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 630-878-0351 |
Mailing Address - Street 1: | 1905 MARKETVIEW DR UNIT 274 |
Mailing Address - Street 2: | |
Mailing Address - City: | YORKVILLE |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60560-1896 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 630-878-0351 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1000 W JEFFERSON ST STE 101 |
Practice Address - Street 2: | |
Practice Address - City: | JOLIET |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60435-6812 |
Practice Address - Country: | US |
Practice Address - Phone: | 814-727-5813 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2013-12-20 |
Last Update Date: | 2013-12-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 019020648 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |