Provider Demographics
NPI:1730674227
Name:105 W MADISON DENTAL PC
Entity Type:Organization
Organization Name:105 W MADISON DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SKIDMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-816-9064
Mailing Address - Street 1:600 FAIRWAY DR STE 206
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1807
Mailing Address - Country:US
Mailing Address - Phone:561-899-4595
Mailing Address - Fax:
Practice Address - Street 1:105 W MADISON ST STE 300
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-4602
Practice Address - Country:US
Practice Address - Phone:561-899-4595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty