Provider Demographics
NPI:1750041935
Name:MYORTHOS ILLINOIS ORTHODONTICS PC
Entity Type:Organization
Organization Name:MYORTHOS ILLINOIS ORTHODONTICS PC
Other - Org Name:IDENTITY ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LONABOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-665-7241
Mailing Address - Street 1:131 DARTMOUTH ST FL 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5297
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1275 E BELVIDERE RD STE 100
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2080
Practice Address - Country:US
Practice Address - Phone:847-499-1178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MYORTHOS ILLINOIS ORTHODONTICS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-12-29
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty