Provider Demographics
NPI:1902042534
Name:DENEMARK PERIODONTAL SPECIALISTS, LTD.
Entity Type:Organization
Organization Name:DENEMARK PERIODONTAL SPECIALISTS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:DENEMARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:630-654-4141
Mailing Address - Street 1:570 VILLAGE CENTER DR
Mailing Address - Street 2:SUITE 202B
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-4520
Mailing Address - Country:US
Mailing Address - Phone:630-654-4141
Mailing Address - Fax:630-654-4242
Practice Address - Street 1:570 VILLAGE CENTER DR
Practice Address - Street 2:SUITE 202B
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-4520
Practice Address - Country:US
Practice Address - Phone:630-654-4141
Practice Address - Fax:630-654-4242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-03
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01090229261223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty