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
StateLicense IDTaxonomies
IL0190206481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty