Provider Demographics
NPI:1790035251
Name:PEDIATRIC DENTISRTY SPECIALISTS P.C.
Entity Type:Organization
Organization Name:PEDIATRIC DENTISRTY SPECIALISTS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:KALB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-256-2501
Mailing Address - Street 1:1103 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2611
Mailing Address - Country:US
Mailing Address - Phone:847-256-2501
Mailing Address - Fax:847-256-2508
Practice Address - Street 1:1103 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2611
Practice Address - Country:US
Practice Address - Phone:847-256-2501
Practice Address - Fax:847-256-2508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190234321223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty