Provider Demographics
NPI:1922168954
Name:BLIVAISS, HOWARD L (DDS)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:L
Last Name:BLIVAISS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 W PETERSON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3306
Mailing Address - Country:US
Mailing Address - Phone:773-509-1234
Mailing Address - Fax:773-509-0495
Practice Address - Street 1:3500 W PETERSON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3306
Practice Address - Country:US
Practice Address - Phone:773-509-1234
Practice Address - Fax:773-509-0495
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice