Provider Demographics
NPI:1861647588
Name:NATHAN BRAVERMAN DMD MD PC
Entity Type:Organization
Organization Name:NATHAN BRAVERMAN DMD MD PC
Other - Org Name:HIGHLAND PARK ORAL MAXILLOFACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BRAVERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:847-433-1516
Mailing Address - Street 1:1770 1ST ST
Mailing Address - Street 2:SUITE 350
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-3200
Mailing Address - Country:US
Mailing Address - Phone:847-433-1516
Mailing Address - Fax:847-433-1548
Practice Address - Street 1:1770 FIRST ST.
Practice Address - Street 2:350
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3200
Practice Address - Country:US
Practice Address - Phone:847-433-1516
Practice Address - Fax:847-433-1548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190235441223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty