Provider Demographics
NPI:1821263740
Name:ARTESIAN DENTAL
Entity Type:Organization
Organization Name:ARTESIAN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HORACE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BROY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DR
Authorized Official - Phone:773-536-1434
Mailing Address - Street 1:227 E 47TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-3903
Mailing Address - Country:US
Mailing Address - Phone:773-536-1434
Mailing Address - Fax:773-536-1378
Practice Address - Street 1:227 E. 47TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653
Practice Address - Country:US
Practice Address - Phone:773-536-1434
Practice Address - Fax:773-536-1378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022596261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental