Provider Demographics
NPI:1922146778
Name:GERALD L WINE DDS AND DANIEL L LASSMAN DDS LTD
Entity Type:Organization
Organization Name:GERALD L WINE DDS AND DANIEL L LASSMAN DDS LTD
Other - Org Name:DIVISION DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NIDZA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALICEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-235-0990
Mailing Address - Street 1:2632 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2950
Mailing Address - Country:US
Mailing Address - Phone:773-235-0980
Mailing Address - Fax:773-235-1249
Practice Address - Street 1:2632 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2950
Practice Address - Country:US
Practice Address - Phone:773-235-0980
Practice Address - Fax:773-235-1249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty