Provider Demographics
NPI: | 1922175223 |
---|---|
Name: | TOOTH FAIRY WORLD PC |
Entity Type: | Organization |
Organization Name: | TOOTH FAIRY WORLD PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT CORPORATION |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MARYLENE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | VITIELLO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 773-947-8884 |
Mailing Address - Street 1: | 1525 E 55TH STREET |
Mailing Address - Street 2: | #303 |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60615 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 773-947-8884 |
Mailing Address - Fax: | 773-327-3331 |
Practice Address - Street 1: | 1525 E 55TH STREET |
Practice Address - Street 2: | #303 |
Practice Address - City: | CHICAGO |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60615 |
Practice Address - Country: | US |
Practice Address - Phone: | 773-947-8884 |
Practice Address - Fax: | 773-327-3331 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-11-29 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 1223P0221X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223P0221X | Dental Providers | Dentist | Pediatric Dentistry | Group - Single Specialty |