Provider Demographics
NPI:1902016520
Name:FAMILY DENTAL CARE OF THE EAST SIDE
Entity Type:Organization
Organization Name:FAMILY DENTAL CARE OF THE EAST SIDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EX DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VARVARESSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-978-1231
Mailing Address - Street 1:10601 S AVENUE E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-6316
Mailing Address - Country:US
Mailing Address - Phone:773-978-5828
Mailing Address - Fax:
Practice Address - Street 1:10601 S AVENUE E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-6316
Practice Address - Country:US
Practice Address - Phone:773-978-5828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty