Provider Demographics
NPI:1821241290
Name:OTRAGEN ORTHODONTICS PC
Entity Type:Organization
Organization Name:OTRAGEN ORTHODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREATMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOYLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-223-8116
Mailing Address - Street 1:1500 SHERMER RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5340
Mailing Address - Country:US
Mailing Address - Phone:224-223-8116
Mailing Address - Fax:
Practice Address - Street 1:1500 SHERMER RD
Practice Address - Street 2:SUITE #100
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-5340
Practice Address - Country:US
Practice Address - Phone:224-223-8116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty