Provider Demographics
NPI:1821261397
Name:BRICKYARD ORTHODONTICS
Entity Type:Organization
Organization Name:BRICKYARD ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:
Authorized Official - Last Name:PANOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-836-7846
Mailing Address - Street 1:6018 W DIVERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1108
Mailing Address - Country:US
Mailing Address - Phone:773-836-7846
Mailing Address - Fax:773-622-6191
Practice Address - Street 1:6018 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1108
Practice Address - Country:US
Practice Address - Phone:773-836-7846
Practice Address - Fax:773-622-6191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty