Provider Demographics
NPI:1710489661
Name:CEDAR RIDGE DENTAL
Entity Type:Organization
Organization Name:CEDAR RIDGE DENTAL
Other - Org Name:OCCLUSAL ENTERPRISE
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GIOVANNI
Authorized Official - Middle Name:
Authorized Official - Last Name:ARISTODEMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-854-0525
Mailing Address - Street 1:2110 W ALGONQUIN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-1370
Mailing Address - Country:US
Mailing Address - Phone:847-854-0525
Mailing Address - Fax:
Practice Address - Street 1:2110 W ALGONQUIN RD
Practice Address - Street 2:
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156-1370
Practice Address - Country:US
Practice Address - Phone:847-854-0525
Practice Address - Fax:847-854-0525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental