Provider Demographics
NPI:1851724975
Name:PALOS PEDIATRIC DENTISTRY, PC
Entity Type:Organization
Organization Name:PALOS PEDIATRIC DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:FACKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:708-280-9234
Mailing Address - Street 1:12800 S RIDGELAND AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-2390
Mailing Address - Country:US
Mailing Address - Phone:708-280-9234
Mailing Address - Fax:
Practice Address - Street 1:12800 S RIDGELAND AVE
Practice Address - Street 2:SUITE H
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-2390
Practice Address - Country:US
Practice Address - Phone:708-280-9234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028264261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental