Provider Demographics
NPI:1710145065
Name:MIDWEST DENTAL GROUP
Entity Type:Organization
Organization Name:MIDWEST DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HORBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-257-6485
Mailing Address - Street 1:2720 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1610
Mailing Address - Country:US
Mailing Address - Phone:773-257-6485
Mailing Address - Fax:
Practice Address - Street 1:2720 W 15TH ST
Practice Address - Street 2:114 KLING
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1610
Practice Address - Country:US
Practice Address - Phone:773-257-6485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019013845122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38932Medicare UPIN